HomeMy WebLinkAbout2013-22 Self Insured Health Benefit Program
RESOLUTION NO.2013- aa`
A RESOLUTION AUTHORIZING THE ESTABLISHMENT AND
GOVERNANCE OF A SELF-INSURED HEALTH BENEFIT PROGRAM
RECITALS:
A. The City of Ashland has a vested interest in providing health benefits to its employees,
retirees and eligible dependents.
B. The City meets all the legal requirements of the state of Oregon to self-fund its health
benefit program.
C. The City has retained a third-party administrator to process health benefits claims
D. The City has secured the appropriate reinsurance to protect the City from catastrophic
individual claims as well as aggregate stop loss insurance to insulate the city from the
risk of multiple large claims in one year.
E. The City has established a restricted Health Benefits Fund and will pre-fund the account
at appropriate levels to pay claims beginning July 1, 2013.
THE CITY OF ASHLAND RESOLVES AS FOLLOWS:
SECTION 1.
The City Council authorizes a change from a fully-insured health benefits plan, to a self-funded
health benefits plan beginning July 1, 2013.
SECTION 2.
The benefits offered by the City of Ashland Benefits Plan and the City of Ashland - Parks
Benefit Plan shall be those described in the plan documents, which are attached as exhibits A and
B, and which is hereby approved by the City Council.
SECTION 3.
The City Council hereby establishes an Employee Health Benefits Advisory Committee
(EHBAC) which will act as a self-directed employee team with representatives from each
employee group and bargaining unit. An administrative policy delineating the duties of the
EHBAC is attached as Exhibit C and is hereby approved by the City Council. The EHBAC will
make recommendations for modification of the employee health plan. Recommendations of the
EHBAC will be forwarded annually to the City Council for inclusion in the plan document.
SECTION 4.
The City Administrator is designated as the Plan Administrator for all City of Ashland Employee
Benefits Plan.
SECTION 5.
This resolution takes effect upon signing by the Mayor.
Page 1 of 2
This resolution was duly PASSED and ADOPTED this day of , 2013, and
takes a ct upon signing by the Mayor. ljlle~5~0
arbara Christensen, City Recorder
SIGNED and APPROVED this day of 2013.
oh Stromberg, Mayor
Revie id as to form: /
David H. Lohman, -City Attorney
Page 2 of 2
Exhibit'A'
Irrigia
CITY OF
-ASHLAND
City of Ashland
Group No.: G0032482
Preferred 90+200 VAR GF 0812
Effective: July 1, 2013
Third Party Administrative Services Provided By:
PaciticSource
HEALTH PLANS
SPD 0713_City of Ashland SingleSource Self-Insured
Exhibit 'A'
SingleSource Self-Insured 2
Exhibit'A'
INTRODUCTION
Welcome to your City of Ashland (also referred to as'the employer or'employer) group health plan. Your
employer offers this coverage to help you and your family members stay well, and to protect you in case
of illness or injury. Your plan includes a wide range of benefits and services, and PacificSource hopes
you will take the time to become familiar with them.
Your employer, who is also the Plan Sponsor, has prepared this document to help you understand how
your plan works and how to use it. This document summarizes the benefits provided under the Preferred
90+200 VAR GF 0812 Plan (referred to as 'the plan' or'this plan' throughout this document). Please read
it carefully and thoroughly. Your benefits are affected by certain limitations and conditions, which require
you to be a wise consumer of health services and to use only those services you need. Also, benefits are
not provided for certain kinds of treatments or services, even if your health care provider recommends
them.
The plan is a self-insured medical plan intended to meet the requirements of Sections 105(b), 105(h), and
106 of the Internal Revenue Code so that the portion of the cost of coverage paid by your Plan Sponsor,
and any benefits received by you through this plan, are not taxable income to you. Your specific tax
treatment will depend on your personal circumstances; the plan does not guarantee any particular tax
treatment. You are solely responsible for any and all federal, state, and local taxes attributable to your
participation in this plan, and the plan expressly disclaims any liability for such taxes.
The plan is 'self-i nsured,' which means benefits are paid from your employers general assets and or trust
funds and are not guaranteed by an insurance company. The Plan Sponsor has contracted with a Third
Party Administratorto perform certain administrative services related to this plan.
PacificSource Health Plans is the Third Party Administrator and provides administrative services for this
plan on behalf of the Plan Sponsor. If anything is unclear to you, PacificSource's staff is available to
answer your questions. Please give them a call or visit them on the Internet at PacificSource.com.
PacificSource looks forward to serving you and your family.
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espahol (800) 624-6052, extensi6n 1009
cs@pacificsource.com
This document serves as the written Plan document and Summary Plan Description (SPD). It is very
important that you review the entire document carefully to confirm a complete understanding of the
benefits available, as well as your responsibility, under the plan.
This document is written in simple, easy-to-understand language. Technical terms are printed in italics
and defined in the Plan Terms and Definitions section. This document explains the services covered by
the plan; the benefit summaries tell you how much this plan pays toward expenses and amounts for
which you are responsible.
As used in this document, the word 'year' refers to the benefit year, which is the 12-month period
beginning January 1 and ending December 31. The word lifetime as used in this document refers to the
period of time you or your eligible dependents participate in this plan or any other Plan Sponsored by the
Plan Sponsor
Any amount you or your eligible dependents have accumulated toward the benefit maximum amounts,
deductible, or out-of-pocket maximum of any immediately prior Plan Sponsored by the Plan Sponsor will
be counted toward the benefit maximum amounts of this plan.
The Plan Sponsor reserves the right to amend, modify, or terminate this plan in any manner, at any time,
which may result in termination or modification of your coverage. If this plan is terminated, any plan
assets will be used to pay for eligible expenses incurred prior to the plan's termination, and such
expenses will be paid as provided under the terms of this plan prior to termination. If there is any conflict
between this document and the underlying plan document(s), the plan document(s) control.
SingleSource Self-Insured 3
Exhibit'A'
SingleSource Self-Insured 4
Exhibit'A'
CONTENTS
MEDICAL BENEFIT SUMMARY 3
PRESCRIPTION BENEFIT SUMMARY 5
CHIROPRACTIC CARE BENEFIT SUMMARY 9
ADDITIONAL ACCIDENT BENEFIT SUMMARY .........................................................11
VISION BENEFIT SUMMARY ......................................................................................13
DENTAL BENEFIT SUMMARY ....................................................................................15
USING THE PROVIDER NETWORK ............................................................................17
Preferred Provider Organization (PPO) .................................................................................................17
What is a PPO .......................................................................................................................................17
Who is Your PPO ...................................................................................................................................17
About Your PPO ....................................................................................................................................17
Non-PPO Providers ...............................................................................................................................18
Example of Provider Payment ...............................................................................................................18
Allowable Amount ..................................................................................................................................18
NETWORK NOT AVAILABLE BENEFITS ...................................................................18
COVERAGE WHILE TRAVELING ................................................................................18
Nonemergency Care While Traveling ....................................................................................................19
Emergency Services While Traveling ....................................................................................................19
FINDING PARTICIPATING PROVIDER INFORMATION .............................................19
TERMINATION OF PROVIDER CONTRACTS ............................................................19
BECOMING ELIBIGLE .................................................................................................20
Who Pays for Your Benefits ...................................................................................................................20
Who is Eligible .......................................................................................................................................20
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD 21
Newborns 21
Adopted Children ...................................................................................................................................21
Family Members Acquired by Marriage .................................................................................................21
Family Members Acquired by Domestic Partnership .............................................................................21
Family Members Placed in Your Guardianship .....................................................................................22
Qualified Medical Child Support Orders.. 22
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD 22
Returning to Work after a Layoff ............................................................................................................22
Returning to Work after a Leave of Absence .........................................................................................22
Returning to Work after Family Medical Leave ......................................................................................22
Special Enrollment Periods ....................................................................................................................23
Dental Enrollment ..................................................................................................................................23
Late Enrollment ......................................................................................................................................23
Member ID Card ....................................................................................................................................24
PLAN SELECTION PERIOD 24
TERMINATING COVERAGE 24
Divorced Spouses ..................................................................................................................................24
Dependent Children 24
Dissolution of Domestic Partnership ......................................................................................................24
Certificates of Creditable Coverage .......................................................................................................25
SingleSource Self-Insured 5
Exhibit 'A'
CONTINUATION OF INSURANCE 25
USERRA CONTINUATION 25
Surviving or Divorced Spouses and Qualified Domestic Partners .........................................................26
COBRA CONTINUATION 26
COBRA Eligibility ...................................................................................................................................26
When Continuation Coverage Ends ......................................................................................................26
Type of Coverage ..................................................................................................................................27
Your Responsibilities and Deadlines .....................................................................................................27
Continuation Premium ...........................................................................................................................27
Keep Your Plan Informed of Address Changes .....................................................................................27
CONTINUATION WHEN YOU RETIRE 27
WORK STOPPAGE 28
Labor Unions ..........................................................................................................................................28
COVERED EXPENSES 28
Medical Necessity ..................................................................................................................................28
Healthcare Providers .............................................................................................................................29
Your Annual Out-of-Pocket Limit 29
MEDICAL BENEFITS 29
About Your Medical Benefits .................................................................................................................29
PLAN BENEFITS ..........................................................................................................31
PREVENTIVE CARE SERVICES 31
PROFESSIONAL SERVICES 32
HOSPITAL AND SKILLED NURSING FACILITY SERVICES 34
OUTPATIENT SERVICES 34
EMERGENCY SERVICES 35
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES 36
Mental Health and Chemical Dependency Services .............................................................................36
Medical Necessity and Appropriateness of Treatment ..........................................................................37
HOME HEALTH AND HOSPICE SERVICES 37
DURABLE MEDICAL EQUIPMENT 38
TRANSPLANT SERVICES 39
Payment of Transplant Benefits .............................................................................................................40
OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS .............................40
BENEFIT LIMITATIONS AND EXCLUSIONS ..............................................................43
Least Costly Setting for Services ...........................................................................................................43
EXCLUDED SERVICES 43
A Note About Optional Benefits .............................................................................................................43
Experimental or Investigational Treatment ............................................................................................47
EXCLUSION PERIODS ................................................................................................50
Exclusion Period for Transplant Benefits ...............................................................................................50
CREDIT FOR PRIOR COVERAGE 50
SingleSource Self-Insured 6
Exhibit 'A'
Evidence of Prior Creditable Coverage .................................................................................................50
HEALTH CARE MANAGEMENT AND PREAUTHORIZATION 50
What is Health Care Management .........................................................................................................50
Case Management .................................................................................................................................51
Individual Benefits Management ............................................................................................................52
HOW TO USE YOUR DENTAL PLAN 52
DENTAL PLAN BENEFITS 52
COVERED DENTAL SERVICES 53
Class I Services - Diagnostic and Preventive Treatment ......................................................................53
Class II Restorative Services - Basic and Restorative Treatment ........................................................53
Class II Complicated Services - Complicated Treatment 53
Class III Services - Major Treatment .....................................................................................................54
EXCLUDED DENTAL SERVICES 54
CLAIMS Procedures 57
Questions about Your Claims ................................................................................................................57
Types of Claims .....................................................................................................................................58
How to File a Claim ................................................................................................................................58
Incomplete Claims .................................................................................................................................60
Notification of Benefit Determination .....................................................................................................60
Adverse Benefit Determination ..............................................................................................................61
Your Right to Appeal ..............................................................................................................................61
Resources For Information And Assistance ..........................................................................................64
Plan Sponsor's Discretionary Authority; Standard of Review ................................................................65
Coordination of Benefits .........................................................................................................................65
Order of Payment When Coordinating with Other Group Health Plans ................................................66
OTHER IMPORTANT PLAN PROVISIONS 67
Assignment of Benefits ..........................................................................................................................67
Proof of Loss ..........................................................................................................................................67
No Verbal Modifications of Plan Provisions ...........................................................................................67
Reimbursement to the Plan ...................................................................................................................68
Subrogation 68
Recovery of Excess Payments ..............................................................................................................69
Right To Receive and Release Necessary Information .........................................................................69
Reliance on Documents and Information ...............................................................................................69
No Waiver ..............................................................................................................................................69
Physician/Patient Relationship ..............................................................................................................70
Plan not responsible for Quality of Health Care ....................................................................................70
Plan is not a Contract of Employment ...................................................................................................70
Right to Amend or Terminate Plan ........................................................................................................70
Applicable Law .......................................................................................................................................70
PRIVACY AND CONFIDENTIALITY 70
Permitted Disclosures of Protected Health Information to the Plan Sponsor ........................................71
No Disclosure of Protected Health Information to the Plan Sponsorwithout Certification by Plan
Sponsor 71
Conditions of Disclosure of Protected Health Information to the Plan Sponsor ....................................71
Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the Plan
Sponsor 72
Required Separation between the Plan and the Plan Sponsor .............................................................72
DEFINITIONS 72
RIGHTS OF PLAN MEMBERS 81
SingleSource Self-Insured 7
Exhibit 'A'
SingleSource Self-Insured 8
Exhibit 'A'
Grandfathered Health Plan
The Plan Sponsor believes this plan is a 'grandfathered health plan' under the Patient
Protection and Affordable Care Act (the Affordable Care Act). As permitted by the
Affordable Care Act, a grandfathered health plan can preserve certain basic health
coverage that was already in effect when that law was enacted. Being a grandfathered
health plan means that your plan may not include certain consumer protections of the
Affordable Care Act that apply to other plans, for example, the requirement for the
provision of preventive health services without any cost sharing. However,
grandfathered health plans must comply with certain other consumer protections in the
Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a
grandfathered health plan and what might cause a plan to change from grandfathered
health plan status can be directed to the Plan Sponsor, or you may contact
PacificSource at:
PacificSource Health Plans
PO Box 7068
Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
SingleSource Self-Insured 1
Exhibit'A'
i
SingleSource Self-Insured 2
Exhibit'A'
MEDICAL BENEFIT SUMMARY
POLICY INFORMATION
Group Name: City of Ashland
Group Number: G0032482
Plan Name: Preferred 90+200 VAR GF 0812
Provider Network: Preferred PSN
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours
Waiting Period for New Employees: 1 st day of the month following one (1) day. A person hired on the
first day of the month is eligible on the first day of the following
month.
ANNUAL DEDUCTIBLE $200 per person / $600 per family
The deductible is an amount of covered medical expenses the member pays each benefit year before the plan's
benefits begin. The deductible applies to all services and supplies except those marked with an asterisk Once a
member has paid a total amount toward covered expenses during the benefit year equal to the per person amount
listed above, the deductible will be satisfied for that person for the rest of that benefit year. Once any covered
family members have paid a combined total toward covered expenses during the benefit year equal to the per
family amount listed above, the deductible will be satisfied for all covered family members for the rest of that benefit
year. Deductible expense is not applied to the out-of-pocket limit.
ANNUAL OUT-OF-POCKET LIMIT
Participating Providers .................................................$700 per person / $1,400 per family
Non-participating Providers ..........................................$1,700 per person / $3,400 per family
Only participating provider expense applies to the participating provider out-of-pocket limit and only non-
participating provider expense applies to the non-participating out-of-pocket limit. Once the participating provider
out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is deducted) for
participating and network not available providers for the rest of that benefit year. Once the non-participating
provider out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the oo-payment is
deducted) for non-participating providers for the rest of that benefit year. Deductibles, co-payments, benefits paid in
full and non-participating provider charges in excess of the allowable fee do not accumulate toward the out-of-
pocket limit. Co-payments and non-participating provider charges in excess of the allowable fee will continue to be
the member's responsibility even after the out-of-pocket limit is met.
ADDITIONAL ACCIDENT BENEFIT
The first $1,000 of covered expenses within 90 days of an accident is covered at no charge and is not subject to
the deductible. The balance is covered as shown below.
The member is responsible for the above deductible and the following co-payments and co-insurance.
PARTICIPATING PROVIDERS/ NON-PARTICIPATING
SERVICE: NETWORK NOT AVAILABLE., PROVIDERS:
PREVENTIVE CARE
Well Baby/Well Child Care 10% co-insurance 30% co-insurance
Routine Physicals No charge* No charge*
Well Woman Visits No charge* No charge*
Immunizations - 0-18 yrs No charge* No charge*
Immunizations - age 19 and over 10%oo-insurance 30% co-insurance
Routine Colonoscopy 10% co-insurance 30% co-insurance
PROFESSIONAL SERVICES
Office and Home Visits 10% co-insurance 30% co-insurance
Office Procedures and Supplies 10% co-insurance 30% co-insurance
Surgery 10% co-insurance 30% co-insurance
Outpatient Rehabilitation Services 10% co-insurance 10% co-insurance
HOSPITAL SERVICES
Inpatient Room and Board 10% co-insurance 30% co-insurance
Inpatient Rehabilitation Services 10% co-insurance 30% co-insurance
Skilled Nursing Facility Care 10% co-insurance 30% co-insurance
SingleSource Self-Insured 3
Exhibit 'A'
OUTPATIENT SERVICES
Outpatient Surgery/Services 10% co-insurance 30% co-insurance
Advanced Diagnostic Imaging 10% co-insurance 30% co-insurance
Diagnostic and Therapeutic Radiology 10% oo-insurance 30% co-insurance
and Lab
URGENT AND EMERGENCY SERVICES
Urgent Care Center Visits 10% co-insurance 30% co-insurance
Emergency Room Visits $100 co-pay/visit plus $100 co-pay/visit plus
10% co-insurance A 10% co-insurance A
Ambulance, Ground 10% co-insurance 10% co-insurance
Ambulance, Air 10% co-insurance 10% co-insurance
MENTAL HEALTH/CHEMICAL DEPENDENCY SERVICES -
Office Visits 10% co-insurance 30% co-insurance
Inpatient Care 10% co-insurance 30% co-insurance
Residential Programs 10% co-insurance 30% co-insurance
OTHER COVERED SERVICES
Allergy Injections 10% co-insurance 30% co-insurance
Durable Medical Equipment 10% co-insurance 30% co-insurance
Home Health Care 10% co-insurance 10% co-insurance
Chiropractic Plus (12 visits/benefit 10% co-insurance 10% co-insurance
year)
A For emergency medical conditions, non-participating providers are paid at the participating
provider level.
' Not subject to annual deductible.
Payment to providers is based on the prevailing or contracted PacificSource fee allowance for covered services. Although
participating providers accept the fee allowance as payment in full, non-participating providers may not. Services of non-
participating providers could result in out-of-pocket expense in addition to the cost share above. Network Not Available (NNA)
payment is allowed when PacificSource has not contracted with providers in the geographical area of the member's residence
or work for a specific service or supply. Payment to providers for NNA is based on the usual, customary, and reasonable
charge for the geographical area in which the charge is incurred.
SingleSource Self-Insured 4
Exhibit'A'
PRESCRIPTION BENEFIT SUMMARY
Your Plan Sponsors health plan includes coverage for prescription drugs and certain other
pharmaceuticals, subject to the information below. Your prescription drug plan qualifies as
creditable coverage for Medicare Part D.
MEMBER COST SHARE (other than for Specialty Drugs)
Each time a covered pharmaceutical is dispensed, you are responsible for the co-payment and/or co-
insurance below:
Tier 1: Tier 1: Tier 1:
Generic Preferred Nonmreferred
From a participating retail pharmacy using the
PacificSource Pharmacy Program (see below):
Up to a 34-day supply: $5 $25 $50
From a participating mail order service (see below):
Up to a 34-day supply: $5 $25 $50
35 to 90-day supply: $10 $50 $100
From a participating retail pharmacy without using Not covered,
the PacificSource Pharmacy Program, or from a except 5-day emergency supply
non-participating pharmacy (see below):
MEMBER COST SHARE FOR SPECIALTY DRUG
Each time a covered specialty drug is dispensed, you are responsible for the co-payment and/or co- -
insurance below:
From the participating specialty pharmacy:
Up to a 30-day supply: Same as retail pharmacy co-payment above
From a participating retail pharmacy, from a
participating mail order service, or from a non- Not covered,
participating pharmacy or pharmaceutical service except 5-day emergency supply
provider:
WHAT HAPPENS WHEN A BRAND NAME DRUG IS SELECTED
Regardless of the reason or medical necessity, if you receive a brand name drug or if your physician
prescribes a brand name drug when a generic is available, you will be responsible for the brand name
drug's co-payment and/or co-insurance.
USING THE PACIFICSOURCE PHARMACY PROGRAM
Retail Pharmacy Network
To use the PacificSource pharmacy program, you must show the pharmacy plan number on the
PacificSource ID card at the participating pharmacy to receive your plan's highest benefit level.
When obtaining prescription drugs at a participating retail pharmacy, the PacificSource pharmacy
program can only be accessed through the pharmacy plan number printed on your PacificSource ID
card. That plan number allows the pharmacy to collect the appropriate co-payment and/or co-insurance
from you and bill PacificSource electronically for the balance.
Mail Order Service
This plan includes a participating mail order service for prescription drugs. Most, but not all, covered
prescription drugs are available through this service. Questions about availability of specific drugs may
be directed to the PacificSource Customer Service Department or to the plan's participating mail order
SingleSource Self-Insured 5
Exhibit 'A'
service vendor. Forms and instructions for using the mail order service are available from PacificSource
and on PacificSource's website, PacificSource.com.
Specialty Drug Program
PacifcSource contracts with a specialty pharmacy services provider for high-cost injectable
medications and biotech drugs. A pharmacist-led CareTeam provides individual follow-up care and
support to covered members with prescriptions for specialty medications by providing them strong
clinical support, as well as the best drug pricing for these specific medications and biotech drugs.
The CareTeam also provides comprehensive disease education and counseling, assesses patient
health status, and offers a supportive environment for patient inquiries.
Participating provider benefits for specialty drugs are available when you use PacificSource's
specialty pharmacy services provider. Specialty drugs are not available through the participating
retail pharmacy network or mail order service. More information regarding PacifcSource's
exclusive specialty pharmacy services provider and health conditions and a list of drugs requiring
preauthorization and/or are subject to pharmaceutical service restrictions is on PacificSource's
website, PacificSource.com.
OTHER COVERED PHARMACEUTICALS
Supplies covered under the pharmacy plan are in place of, not in addition to, those same covered
supplies under the medical plan. Member cost share for items in this section are applied on the
same basis as for other prescription drugs, unless otherwise noted.
Diabetic Supplies
• Insulin, diabetic syringes, lancets, and test strips are available.
• Glucagon recovery kits are available for the plan's preferred brand name co-payment.
• Glucostix and glucose monitoring devices are not covered under this pharmacy benefit, but are
covered under the medical plan's durable medical equipment benefit.
Contraceptives
• Oral contraceptives
• Implantable contraceptives, contraceptive injections, contraceptive patches, and contraceptive rings
are available.
• Diaphragm or cervical caps are available.
Tobacco Cessation
Program specific tobacco cessation medications are covered with active participation in a plan
approved tobacco cessation program (see Preventive Care in the policy's Covered Expenses section).
Orally Administered Anticancer Medications
Orally administered anticancer medications used to kill or slow the growth of cancerous cells are
available. Co-payments for orally administered anticancer medication are applied on the same basis as
for other drugs. Orally administered anticancer medications covered under the pharmacy plan are in
place of, not in addition to, those same covered drugs under the medical plan.
LIMITATIONS AND EXCLUSIONS
• This plan only covers drugs prescribed by a licensed physician (or other licensed practitioner
eligible for reimbursement under your plan) prescribing within the scope of his or her professional
license, except for:
- Over-the-counter drugs or other drugs that federal law does not prohibit dispensing without a
prescription (even if a prescription is required under state law).
- Drugs for any condition excluded under the health plan. That includes drugs intended to
promote fertility, treatments for obesity or weight loss, tobacco cessation drugs (except as
specifically provided for under Other Covered Pharmaceuticals), experimental drugs, and drugs
available without a prescription (even if a prescription is provided).
- Some specialty drugs that are not self-administered are not covered by this pharmacy benefit,
but are covered under the medical plan's office supply benefit.
SingleSource Self-Insured 6
Exhibit 'A'
- Immunizations (although not covered by this pharmacy benefit, immunizations may be covered
under the medical plan's preventive care benefit).
- Drugs and devices to treat erectile dysfunction.
- Drugs used as a preventive measure against hazards of travel.
- Vitamins, minerals, and dietary supplements, except for prescription prenatal vitamins and
fluoride products, and for services that have a rating of 'A' or'B' from the U.S Preventive
Services Task Force (USPSTF).
• Certain drugs require preauthorization by PacificSource in order to be covered. An up-to-date list of
drugs requiring preauthorization is available on PacificSource's website, PacificSource.com.
• PacificSource may limit the dispensing quantity through the consideration of medical necessity,
generally accepted standards of medical practice, and review of medical literature and
governmental approval status.
• Quantities for any drug filled or refilled are limited to no more than a 34-day supply when purchased
at retail pharmacy or a 90-day supply when purchased through mail order pharmacy service or a
30-day supply when purchased through a specialty pharmacy.
• For drugs purchased at non-participating pharmacies or at participating pharmacies without using
the PacificSource pharmacy program, reimbursement is limited to an allowable fee.
• Non-participating pharmacy charges are not eligible for reimbursement unless you have a true
medical emergency that prevents you from using a participating pharmacy. Drugs obtained at a
non-participating pharmacy due to a true medical emergency are limited to a 5 day supply.
• The member cost share for prescription drugs (co-payments, co-insurance, and service charges)
does not apply to the medical deductible or out-of-pocket limit of the policy. You continue to be
responsible for the prescription drug co-payments and service charges regardless of whether the
policy's out-of-pocket limit is satisfied.
• Prescription drug benefits are subject to your plan's coordination of benefits provision. (For more
information see Claims Payment - Coordination of Benefits in your Summary Plan Description.)
GENERAL INFORMATION ABOUT PRESCRIPTION DRUGS
A drug formulary is a list of preferred medications used to treat various medical conditions. The
formulary for this plan is known as the Preferred Drug List (PDL). The drug formulary is used to help
control rising healthcare costs while ensuring that you receive medications of the highest quality. It is a
guide for your physician and pharmacist in selecting drug products that are safe, effective, and cost
efficient. The drug formulary is made up of name brand products. A complete list of medications
covered under the drug formulary is available on the For Members area on PacificSource's website,
PacifcSource.com. The drug formulary is developed by Caremark@ in cooperation with PacificSource.
Non-preferred drugs are covered brand name medications not on the drug formulary.
Generic drugs are equivalent to name brand medications. By law, they must have the same active
ingredients as the brand name medication and are subject to the same standards of their brand name
counterpart. Name brand medications lose their patent protection after a number of years. Any drug
company can then produce the drug, and the manufacturer must pass the same strict FDA standards of
quality and product safety as the original manufacturer. Generic drugs are less expensive than brand
name drugs because there is more competition and there is no need to repeat costly research and
development. Your pharmacist and physician are encouraged to use generic drugs whenever they are
available.
SingleSource Self-Insured 7
Exhibit 'A'
SingleSource Self-Insured 8
Exhibit'A'
CHIROPRACTIC CARE BENEFIT SUMMARY
Your plan's chiropractic care benefit allows you to receive treatment from licensed chiropractors for
medically necessary diagnosis and treatment of illness or injury. Refer to the Medical Benefit Summary
for your co-payment and/or co-insurance information.
PacificSource contracts with a network of chiropractors, so you can reduce your out-of-pocket expense
by using one of the participating providers. For a listing of participating chiropractors in your area,
please refer to your plan's participating provider directory, visit our website, Pacificsource.com, or call
our Customer Service Department.
Covered Services
• Chiropractic manipulation, massage therapy, and any laboratory services, x-rays, radiology, and
durable medical equipment provided by or ordered by a chiropractor.
The combined benefit for all treatments, services, and supplies provided or ordered by a chiropractor is
limited to 12 visits per person in any benefit year.
Excluded Services
• Any service or supply excluded or not otherwise covered by the medical plan.
• Drugs, homeopathic medicines, or homeopathic supplies furnished by a chiropractor.
• Services of an alternative care provider for pregnancy or childbirth.
r
SingleSource Self-Insured 9
Exhibit'A'
SingleSource Self-Insured 10
Exhibit 'A'
ADDITIONAL ACCIDENT BENEFIT SUMMARY
In the event of an injury caused by an accident, first dollar benefits are provided for covered expenses
according to the following:
Related Definitions
'Accident' means an unforeseen or unexpected event causing injury that requires medical attention.
'Injury' means bodily trauma or damage which is independent of disease or infirmity. The damage must
be caused solely through external and accidental means. Injury, for the purpose of this benefit, does not
include musculoskeletal sprains or strains obtained in the performance of physical activity.
Covered Expenses
Benefits for the following covered expenses are provided, subject to the limitations stated below:
• Services or supplies provided by a physician (except orthopedic braces)
• Services of a hospital
• Services of a registered nurse who is unrelated to the injured person by blood or marriage
• Services of a registered physical therapist
• Services of a physician or a dentist for the repair of a fractured jaw or natural teeth
• Diagnostic radiology and laboratory services
• Transportation by local ground ambulance
Limitations
• The treatment must be medically necessary for the injury.
• The treatment or service must be provided within 90 days after the injury occurs.
• The first $1,000 of covered expense is paid at 100% and is not subject to the deductible.
SingleSource Self-Insured 11
Exhibit 'A'
SingleSource Self-Insured 12
Exhibit'A'
VISION BENEFIT SUMMARY
Your Plan Sponsor covers vision exams, eyeglasses, and contact lenses. The following shows the
vision benefits available.
Benefit Period
Eye Exam: Once every 12 months for covered children. Once every 24 months for
covered adults.
Lenses: Once every 12 months for covered children. Once every 24 months for
covered adults.
Frames: Once every 24 months for all covered individuals OR
Contact lenses: Once every 12 months for covered children. Once every 24 months for
covered adults.
Member Responsibility
PARTICIPATING NON-PARTICIPATING
SERVICE/SLIPPLY PROVIDERS: PROVIDERS:
Eye Exam No charge No charge up to a
$71 maximum
Hardware
Lenses (maximum per pair)
Single Vision No charge No charge up to a
$51 maximum
Bifocal No charge No charge up to a
$77 maximum
Trifocal No charge No charge up to a
$100 maximum
Lenticular No charge Not covered
Progressive No charge Not covered
Frames No charge up to a No charge up to a
$120 maximum $66 maximum
Contacts (in place of No charge up to a No charge up to a
glasses) $166 maximum $166 maximum
The amounts listed above are the maximum benefits available for all vision exams, lenses, and
frames furnished during any benefit period when prescribed by a licensed ophthalmologist or
licensed optometrist. Participating providers discount hardware services.
Limitations and Exclusions
The out-of-pocket expense for vision services (co-payments and service charges) does not apply
to the medical plan's deductible or out-of-pocket limit. Also, the member continues to be
responsible for the vision co-payments and service charges regardless of whether the medical
plan's out-of-pocket limit is satisfied.
Covered expenses do not include, and no benefits are payable for:
• Special procedures such as orthoptics or vision training
• Special supplies such as sunglasses (plain or prescription) and subnormal vision aids
• Tint
SingleSource Self-Insured 13
Exhibit'A'
• Plano contact lenses
• Anti-reflective coatings and scratch resistant coatings
• Separate charges for contact lens fitting
• Replacement of lost, stolen, or broken lenses or frames
• Duplication of spare eyeglasses or any lenses or frames
• Nonprescription lenses
• Visual analysis that does not include refraction
• Services or supplies not listed as covered expenses
• Eye exams required as a condition of employment, or required by a labor agreement or government
body
• Expenses covered under any worker's compensation law
• Services or supplies received before this plan's coverage begins or after it ends
• Charges for services or supplies covered in whole or in part under any other medical or vision
benefits provided by the Plan Sponsor
• Medical or surgical treatment of the eye
Important information about your vision benefits
Your Plan Sponsor's health plan includes coverage for vision services, including prescription
eyeglasses and contact lenses. To make the most of those benefits, it's important to keep in mind
the following:
• Participating Providers
PacificSource is able to add value to your vision benefits by contracting with a network of vision
providers. Those providers offer vision services at discounted rates, which are passed on to you in
your benefits.
• Paying for Services
Please remember to show your current PacificSource ID card whenever you use your plan's
benefits. PacificSource's provider contracts require participating providers to bill us directly
whenever you receive covered services and supplies. Providers normally call PacificSource to
verify your vision benefits. Participating providers should not ask you to pay the full cost in
advance. They may only collect your share of the expense up front, such as copayments and
amounts over your plan's allowances. If you are asked to pay the entire amount in advance,
tell the provider you understand they have a contract with PacificSource and should bill
PacificSource directly.
• Sales and Special Promotions
Vision retailers often use coupons and promotions to bring in new business, such as free eye
exams, two-for-one glasses, or free lenses with purchase of frames. Because participating
providers already discount their services through their contract with PacificSource, your plan's
participating provider benefits cannot be combined with any other discounts or coupons. You can
use your plan's participating provider benefits, or you can use your plan's non-participating provider
benefits to take advantage of a sale or coupon offer. If you do take advantage of a special offer, the
participating provider may treat you as an uninsured customer and require full payment in advance.
You can then send the claim to PacificSource yourself, and PacificSource will reimburse you
according to your plan's non-participating provider benefits.
PacificSource hopes this information helps clarify your vision benefits. If you or your provider have any
questions about your benefits, please call PacificSource Customer Service at (541) 686-1242 from
Eugene-Springfield or (888) 977-9299 from other areas.
SingleSource Self-Insured 14
Exhibit'A'
DENTAL BENEFIT SUMMARY
POLICY INFORMATION
Group Name: City of Ashland
Group Number: G0032482
Plan Name: Preferred Incentive Dental $1500 VAR 0711
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours
Waiting Period for New Employees: 1st day of the month following one (1) day. A person hired on the
first day of the month is eligible on the first day of the following
month.
DENTAL BENEFIT SUMMARY
Subject to all the terms of this Group Dental Policy, the Plan Sponsor will pay a dental benefit for
covered dental expenses incurred by a covered person. The dental benefit is a percentage of the usual,
customary, and reasonable charge for covered dental expenses incurred, subject to an annual
maximum benefit, and an annual deductible, as follows:
Maximum Payment
The amount payable by this plan for covered services received under Class I are unlimited. The
maximum amount payable by this plan for covered Class It and Class III services received each benefit
year, or portion thereof, for each eligible patient is limited to $1,500.
PLAN PAYMENT SCHEDULE
Class I Services- Plan pays 70% toward covered Class I Services - Diagnostic and
Preventive Treatment.
Class II Restorative Services- Plan pays 70% toward covered Class 11 Restorative Services -
Restorative Treatment.
Class II Complicated Services- Plan pays 70% toward covered Class 11 Complicated Services -
Complicated Treatment.
Class III Services- Plan pays 70% toward covered Class III Services - Major Treatment.
This plan pays the percentage indicated above toward Class 1, 11 and III Services during the first year an
individual is eligible. Payment increases 10 percent (to a maximum benefit of 100 percent) each
successive benefit year for Class I, II and III Services if the member visits a dentist at least once during
the benefit year. Payment decreases 10 percent (to a minimum benefit of the percentage stated above)
each successive benefit year if the member does not visit a dentist at least once during the previous
benefit year.
SingleSource Self-Insured 15
Exhibit'A'
SingleSource Self-Insured 16
Exhibit'A'
USING THE PROVIDER NETWORK
This section explains how your plan's benefits differ when you use participating and non-participating
providers. This information is not meant to prevent you from seeking treatment from any provider if you
are willing to take increased financial responsibility for the charges incurred.
All healthcare providers are independent contractors. Neither your Plan Sponsor nor PacificSource can
be held liable for any claim or damages for injuries you experience while receiving medical care.
Preferred Provider Organization (PPO)
What is a PPO
A preferred provider organization (PPO) has made agreements with hospitals, physicians, practitioners,
and other health care providers to discount the cost of services they provide.
Who is Your PPO
The Plan Sponsor has chosen PacificSource to provide PPO services for employees and eligible
dependents in Oregon, Idaho, and Montana service areas and in bordering communities in southwest
Washington. They also have an agreement with a nationwide provider network, The First Health@
Network. The First Health providers outside PacificSource's service area are also considered
participating providers under your plan.
A list of participating providers can be accessed through the PacificSource website: PacificSource.com
or by calling PacificSource at (888) 977-9299. This list of participating providers is updated regularly.
About Your PPO
PacificSource has selected the participating physicians, practitioners, and hospitals after carefully
reviewing their qualifications. Each health care provider has agreed to a contracted amount in payment
for their services. Additionally, you cannot be 'balanced billed' for the difference between the PPO
contracted amount and the provider's normal billed charge for a particular service. You are only
responsible for the deductible, copayment, and/or coinsurance payment shown on the Medical Benefit
Summary.
Enrolling in this plan does not guarantee that a particular participating providerwill remain a
participating provideror that a particular participating providerwill provide members under this plan only
with covered services. Members should verify a health care provider's status as a participating provider
each time services are received from the health care provider.
It is not safe to assume that when you are treated at a participating medical facility, all services are
performed by participating providers. A list of participating providers can be accessed through the
PacificSource website: PacificSource.com or by calling PacificSource at (888) 977-9299. Whenever
possible, you should arrange for professional services such as surgery and anesthesiology to be
provided by a participating provider. Doing so will help you maximize your benefits and limit your out-of-
pocket expenses. The PPO benefits are outlined on the Medical Benefit Summary.
You have a free choice of any health care provider, and the physician-patient relationship shall be
maintained. Members, together with their health care provider, are ultimately responsible for
determining the appropriate course of medical treatment, regardless of whether the plan will pay for all
or a portion of the cost of such care. The participating providers are merely independent contractors;
neither the plan, the Plan Sponsor, nor PacificSource makes any warranty as to the quality of care that
maybe rendered by any participating provider. I .
This plan generally allows the designation of a primary care provider. You have the right to designate
any primary care provider who participates in the network and who is available to accept you or your
family members. For children, you may designate a pediatrician as the primary care provider. You do
not need prior authorization from this plan or from any other person (including a primary care provider)
in order to obtain access to obstetrical or gynecological care from a health care professional in the
network who specializes in obstetrics or gynecology. The health care 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 for making referrals. For a list of the
SingleSource Self-Insured 17
Exhibit'A'
participating providers and/or a list of participating health care professionals who specialize in obstetrics
or gynecology, contact PacificSource at (888) 977-9299 or PO Box 7068, Springfield, OR 97475-0068.
Non-PPO Providers
When you receive services or supplies from a nonparticipating provider, your out-of-pocket expense is
likely to be higher than if you had used a participating provider. Besides the non-PPO deductible,
copayment, and/or coinsurance amounts shown on the Medical Benefit Summary, you may become
responsible for the provider's billed amount that exceeds the plan's allowable amount.
Example of Provider Payment
The following illustrates how payment could be made for a covered service billed at $120. In this
example, the Medical Benefit Summary shows a participating providers co-insurance of 20 percent and
a non-participating providers co-insurance of 30 percent. This is only an example; your plan's benefits
may be different.
Participating Non-participating
Provider Provider
Provider's usual billed charge $120 $120
PPG's negotiated provider discount $20 $0
Plan's allowable amount $100 $100
Percent of payment 20% 30%
Plan's payment $80 $70
Patient's amount of allowable amount $20 $30
Charges above the allowable amount $0 $20
Patient's total payment to provider $20 $50
Percent of charge paid by plan 80% 58%
Percent of charge paid by patient 20% 42%
Allowable Amount
The plan bases payment to nonparticipating providers on an allowable amount for the same services or
supplies. Several sources are used to determine the allowable amount, depending on the service or
supply and the geographical area where it is provided. The allowable amount may be based on data
collected from the Centers for Medicare and Medicaid Services (CMS), Viant Health Payment
Solutions, other nationally recognized databases, or PacificSource.
NETWORK NOT AVAILABLE BENEFITS
The term 'network not available' is used when a member does not have reasonable geographic access
to a participating provider for a covered medical service or supply.
If you live in an area without access to a participating provider for a specific service or supply, your
plan's Network Not Available benefits apply. Here's how that works:
• You seek treatment from a nearby non-participating provider of that service or supply.
• PacificSource determines the allowable fee for that service or supply (the term 'allowable fee' is
explained above under the Non-participating Providers section).
• PacificSource applies the Network Not Available benefit level stated in your Medical Benefit
Summary to the allowable fee to calculate covered expenses.
• You are responsible for any co-payments, co-insurance, deductibles, and amounts over the
allowable fee.
COVERAGE WHILE TRAVELING
Your plan is powered by the PacificSource Network (PSN). The PSN Network covers Oregon, Idaho,
Montana, southwest Washington, and eastern Washington. When you need medical services outside of
the PSN Network, you can save out-of-pocket expense by using the participating providers available
through The First Health@ Network.
SingleSource Self-Insured 18
Exhibit'A'
Nanemergency Care While Traveling
To find a participating provider outside the regions covered by the PacificSource Network, call The First
Health® Network at (800) 226-5116. (The phone number is also printed on your PacificSource ID card
for convenience.) Representatives are available at any time to help you find a participating physician,
hospital, or other outpatient provider. Nonemergency care outside of the United States is not covered.
• If a participating provider is available in your area, your plan's participating provider benefits will
apply if you use a participating provider.
• If a participating provider is not available in your area, your plan's Network Not Available benefits
will apply.
• If a participating provider is available but you choose to use a non-participating provider, your plan's
non-participating provider benefits will apply.
Emergency Services While Traveling
In medical emergencies (see the Covered Expenses - Emergency Services section of this Summary
Plan Description), your plan pays benefits at the participating provider level regardless of your location.
Your covered expenses are based on PacificSource's allowable fee. If you are admitted to a hospital as
an inpatient following the stabilization of your emergency condition, your physician or hospital should
contact the PacificSource Health Services Department at (888) 691-8209 as soon as possible to make
a benefit determination on your admission. If you are admitted to a non-participating hospital,
PacificSource may require you to transfer to a participating facility once your condition is stabilized in
order to continue receiving benefits at the participating provider level.
FINDING PARTICIPATING PROVIDER INFORMATION
You can find up-to-date participating provider information:
• By asking your healthcare provider if he or she is a participating provider for your Plan Sponsor's
plan.
• On the PacificSource website, PacificSource.com. Simply click on'Find a Provider and you can
easily look up participating providers or print your own customized directory.
• By contacting the PacificSource Customer Service Department. PacificSource can answer your
questions about specific providers. If you'd like a complete provider directory for your plan, just ask
- PacificSource will be glad to mail you a directory free of charge.
• By calling The First Health® Network at (800) 226-5116 if you live outside the area covered by the
PacificSource Network.
TERMINATION OF PROVIDER CONTRACTS
PacificSource will notify you within ten days of learning of the termination of a provider contractual
relationship if you have received services in the previous three months from such a provider when:
• A provider terminates a contractual relationship with PacificSource in accordance with the terms
and conditions of the agreement;
• A provider terminates a contractual relationship with an organization under contract with
PacificSource; or
PacificSource terminates a contractual relationship with an individual provider or the organization
with which the provider is contracted in accordance with the terms and conditions of the agreement.
For the purposes of continuity of care, PacificSource may require the provider to adhere to the medical
services contract and accept the contractual reimbursement rate applicable at the time of contract
termination.
SingleSource Self-Insured 19
Exhibit 'A'
BECOMING ELIBIGLE
Who Pays for Your Benefits
The Plan Sponsor shares the cost of providing benefits for you and your enrolled dependents. From
time to time, the Plan Sponsor may adjust the amount of contributions required for coverage. In
addition, the deductibles and copayments may also change periodically. You will be notified by your
Plan Sponsor of any changes in the cost of plan coverage before they take effect.
Who is Eligible
Employees - You are eligible to participate in this plan if you are a regular, full-time employee of the
Plan Sponsor upon the completion of the minimum number of hours and probationary waiting period set
by your Plan Sponsor. Your Plan Sponsor's eligibility requirements are stated in your Medical Benefit
Summary. All employees who meet those requirements are eligible for coverage.
Eligibility for Medicaid or the receipt of Medicaid benefits will not be taken into account in determining
eligibility. Status as an employee is determined under the employment records of the Plan Sponsor.
Workers classified by the Plan Sponsor as independent contractors are not eligible for this plan under
any circumstances.
Retirees - You are eligible to participate in this plan if you are a retired employee of the Plan Sponsor,
or a spouse of a retired employee. Eligibility for Medicaid or the receipt of Medicaid benefits will not be
taken into account in determining eligibility.
Dependents - While you are enrolled under this plan, the following family members, and only the
following family members, are also eligible to participate in the plan:
• Your legal spouse or qualified domestic partner. The Plan Sponsor may require documentation
proving a legal marital relationship, an Affidavit of Domestic Partnership or a Certificate of Qualified
domestic partnership.
• Your, your spouse's, or your qualified domestic partner's dependent children under age 26
regardless of the child's place of residence, marital status, or financial dependence on you.
• Your, your spouse's, or your qualified domestic partner's unmarried dependent children age 26 or
over who are mentally or physically disabled. To quality as dependents, they must have been
continuously unable to support themselves since turning age 26 because of a mental or physical
disability. PacificSource requires documentation of the disability from the child's physician, and will
review the case before determining eligibility for coverage.
• Your grandchildren. A child of an eligible dependent enrolled on your plan under age 19 who is
unmarried, not in a domestic partnership, registered or otherwise, who is related to you by blood,
marriage, or domestic partnership AND for whom you are the court appointed legal custodian or
guardian with the expectation that the family member will live in your household for at least a year.
• A child placed for adoption with you, your spouse, or qualified domestic partner. Placed for
adoption means the assumption and retention by you, your spouse, or qualified domestic partner of
a legal obligation for total or partial support of a child in anticipation of adoption or placement for
adoption. Upon any termination of such legal obligations the placement for adoption shall be
deemed to have terminated.
• 'Dependent children' means any natural, step, or adopted children as well as any child placed for
adoption with you or your domestic partner are legally obligated to support or contribute support for.
It may also include grandchildren under age 19 who are unmarried and expected to live in your
household for at least a year, if you are the court appointed legal custodian or guardian.
No family or household members other than those listed above are eligible to enroll under your
coverage.
Special Rules for Eligibility - At any time, the Plan Administrator may require proof that a person
qualifies or continues to qualify as a dependent as defined by this plan.
SingleSource Self-Insured 20
Exhibit'A'
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD
The 'initial enrollment period' is the 60-day period beginning on the date a person is first eligible for
enrollment in this plan. Everyone who becomes eligible for coverage has an initial enrollment period.
When you satisfy your Plan Sponsor's probationary waiting period at the hours required for eligibility
and become eligible to enroll in this plan, you and your eligible family members must enroll within the
initial enrollment period. If you miss your initial enrollment period, you may be subject to a waiting
period. (For more information, see 'Special Enrollment Periods' and 'Late Enrollment' under the
Enrolling After the Initial Enrollment Period section.) To enroll, you must complete and sign an
enrollment application, which is available from your Plan Sponsor. The application must include
complete information on yourself and your enrolling family members. Return the application to your
Plan Sponsor, and your Plan Sponsorwill send it to PacificSource.
Coverage for you and your enrolling family members begins on the first day of the month after you
satisfy your Plan Sponsors probationary waiting period. The probationary waiting period is stated in
your Medical Benefit Summary. Coverage will only begin if Your Plan Sponsor receives your enrollment
application and premium.
Newborns
Your, your spouse's, or your qualified domestic partner's natural born baby is eligible for
enrollment under this plan during the 60-day initial enrollment period after birth. PacificSource
cannot enroll the child and pay benefits until your Plan Sponsor receives an enrollment application
listing the child as your dependent. A claim for maternity care is not considered notification for the
purpose of enrolling a newborn child. Anytime there is a delay in providing enrollment information,
your Plan Sponsor may ask for legal documentation to confirm validity.
Adopted Children
When a child is placed in your home for adoption, the child is eligible for enrollment under this plan
during the 60-day initial enrollment period after placement for adoption. 'Placement for adoption' means
the assumption and retention by you, your spouse's, or your domestic partner's of a legal obligation for
full or partial support and care of the child in anticipation of adoption of the child. To add the child to
your coverage, you must complete and submit an enrollment application listing the child as your
dependent. You may be required to submit a copy of the certificate of adoption or other legal
documentation from a court or a child placement agency to complete enrollment.
If additional premium is required, then the natural born or adopted child's eligibility for enrollment will
end 60 days after placement if Plan Sponsor has not received an enrollment application and premium.
Premium is charged from the date of placement and prorated for the first month.
If no additional premium is required, then the natural born or adopted child's eligibility continues as long
as you are covered. However, PacificSource cannot enroll the child and pay benefits until your Plan
Sponsor receives an enrollment application listing the child as your dependent.
Family Members Acquired by Marriage
If you marry, you may add your new spouse and any newly eligible dependent children to your
coverage during the 60-day initial enrollment period after the marriage. Your Plan Sponsor must receive
your enrollment application and additional premium during the initial enrollment period. Coverage for
your new family members will then begin on the first day of the month after the marriage. You may be
required to submit a copy of your marriage certificate to complete enrollment.
Family Members Acquired by Domestic Partnership
If you and your same-gender domestic partner have been issued a Certificate of Qualified domestic
partnership, your domestic partner and your partner's dependent children are eligible for coverage
during the 60-day initial enrollment period after the registration of the domestic partnership. Your Plan
Sponsor must receive your enrollment application and additional premium during the initial enrollment
period. Coverage for your new family members will then begin on the first day of the month after the
registration of the domestic partnership. You may be required to submit a copy of your Certificate of
Qualified domestic partnership to complete enrollment.
SingleSource Self-Insured 21
Exhibit'A'
Unregistered same-gender domestic partners and their children may also become eligible for
enrollment. If you and your unqualified domestic partner meet the criteria on the Affidavit of Domestic
Partnership supplied by your Plan Sponsor, your domestic partner and your partner's dependent
children are eligible for coverage during the 60-day initial enrollment period after the requirements of
the Affidavit of Domestic Partnership are satisfied. Your Plan Sponsor must receive your enrollment
application, a notarized copy of your Affidavit of Domestic Partnership, and additional premium during
the initial enrollment period. Coverage for your new family members will then begin on the first day of
the month after the Affidavit of Domestic Partnership is notarized.
Family Members Placed in Your Guardianship
If a court appoints you custodian or guardian of an eligible grandchild, you may add that family member
to your coverage. To be eligible for coverage, the family member must be:
• Unmarried;
• Not in a domestic partnership, registered or otherwise;
• Related to you by blood, marriage, or domestic partnership;
• Under age 19; and
• Expected to live in your household for at least a year.
Your Plan Sponsor must receive your enrollment application and additional premium during the 60-day
initial enrollment period beginning on the date of the court appointment. Coverage will then begin on the
first day of the month following the date of the court order. You may be required to submit a copy of the
court order to complete enrollment.
Qualified Medical Child Support Orders
This health plan complies with qualified medical child support orders (QMCSO) issued by a state court
or state child support agency. A QMCSO is a judgment, decree, or order, including approval of a
settlement agreement that provides for health benefit coverage for the child of a plan member.
If a court or state agency orders coverage for your spouse or child, they may enroll in this plan within
the 60-day initial enrollment period beginning on the date of the order. Coverage will become effective
on the first day of the month after Plan Sponsor receives the enrollment application. You may be
required to submit a copy of the QMCSO to complete enrollment.
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD
Returning to Work after a Layoff
If you are laid off and then rehired by your Plan Sponsor within six months, you will not have to satisfy
another probationary waiting period or new exclusion period. ,
Your health coverage will resume the first of the month following the date you return to work and again
meet your Plan Sponsor's minimum hour requirement. If your family members were covered before
your layoff, they can resume coverage at that time as well. You must re-enroll your family members by
submitting an enrollment application within the 60-day initial enrollment period following your return to
work.
Returning to Work aftera Leave of Absence
If you return to work after a Plan Sponsor-approved leave of absence of six months or less, you will not
have to satisfy another probationary waiting period. Your health coverage will resume the day you
return to work and again meet your Plan Sponsor's minimum hour requirement. If your family members
were covered before your leave of absence, they can resume coverage at that time as well. You must
re-enroll your family members by submitting an enrollment application within the 60-day initial
enrollment period following your return to work.
Returning to Work after Family Medical Leave
Your Plan Sponsor is probably subject to the Family Medical Leave Act (FMLA). To find out if you have
rights under FMLA, ask your health plan administrator. Under FMLA, if you return to work after a
SingleSource Self-Insured 22
Exhibit 'A'
qualifying FMLA medical leave, you will not have to satisfy another probationary waiting period or any
previously satisfied exclusion period under this plan. Your health coverage will resume the day you
return to work and meet your Plan Sponsor's minimum hour requirement. If your family members were
covered before your leave, they can also resume coverage at that time if you re-enroll them within the
60-day initial enrollment period following your return.
Special Enrollment Periods
If you are eligible to decline coverage and you wish to do so, you must submit a written waiver of
coverage to your Plan Sponsor. You and your family members may enroll in this plan later if you qualify
under Rule #1, Rule #2, or Rule #3 below.
• Special Enrollment Rule #1 - If you declined enrollment for yourself or your family members
because of other health insurance coverage, you or your family members may enroll in the plan
later if the other coverage ends involuntarily. 'Involuntarily' means coverage ended because
continuation coverage was exhausted, employment terminated, work hours were reduced below
the Plan Sponsor's minimum requirement, the other insurance plan was discontinued or the
maximum lifetime benefit of the other plan was exhausted, the Plan Sponsor's premium
contributions toward the other insurance plan ended, or because of death of a spouse, divorce, or
legal separation. To do so, you must request enrollment within 60 days after the other health
insurance coverage ends (or within 60 days after the other health insurance coverage ends if the
other coverage is through Medicaid or a State Children's Health Insurance Program). Coverage will
begin on the first day of the month after the other coverage ends.
• Special Enrollment Rule #2 - If you acquire new dependents because of marriage, qualification of
domestic partnership, birth, or placement for adoption, you may be able to enroll yourself and/or
your newly acquired eligible dependents at that time. To do so, you must request enrollment within
60 days after the marriage, registration of the domestic partnership, birth, or placement for
adoption. In the case of marriage or domestic partnership, coverage begins on the first day of the
month after the marriage or registration of the domestic partnership. In the case of birth or
placement for adoption, coverage begins on the date of birth or placement.
• Special Enrollment Rule #3 - If you or your dependents become eligible for a premium assistance
subsidy under Medicare or CHIP, you may be able to enroll yourself and/or your dependents at that
time. To do so, you must request enrollment within 60 days of the date you and/or your dependents
become eligible for such assistance. Coverage will begin on the first day of the month after
becoming eligible for such assistance.
Dental Enrollment
Employees or their dependents who did not enroll with dental benefits when initially eligible may later
enroll on the policy's anniversary date. Employees and/or dependents who enrolled with dental benefits
under this policy but later terminated coverage may enroll on an anniversary date of the policy following
a 24-month waiting period from the date coverage was last terminated.
Late Enrollment
If you did not enroll during your initial enrollment period and you do not qualify for a special
enrollment period, your enrollment will be delayed until the plan's anniversary date.
A'late enrollee' is an otherwise eligible employee or dependent who does not qualify for a special
enrollment period explained above, and who:
• Did not enroll during the 60-day initial enrollment period, or
• Enrolled during the initial enrollment period but discontinued coverage later.
A late enrollee may enroll by submitting an enrollment application to your Plan Sponsor during an open
enrollment period designated by your Plan Sponsorjust prior to the plan's anniversary date. When you
or your dependents enroll during the open enrollment period, plan coverage begins on the date Plan
Sponsor receives the enrollment application or on the plan's anniversary date.
You may enroll in coverage prior to an open enrollment period if one of the following exceptions are
met:
SingleSource Self-Insured 23
Exhibit'A'
• You and/or your dependent may enroll in coverage if you involuntary lose other Group Coverage or
lose coverage under the Oregon Health Plan.
• You and/or your dependent may enroll in coverage if your hours per week are increased or your
employer's contribution is increased. You and/or your dependent may also enroll if you return from
a qualified FMLA leave.
Member ID Card
The membership card issued to you by PacificSource is for identification purposes only. Possession of
a membership card confers no right to services or benefits under this plan and misuse of your
membership card may be grounds for termination of your coverage under this plan. To be eligible for
services or benefits under this plan, you must be eligible and enrolled in the plan and you must present
the membership card to your health care provider. If you receive services or benefits for which you are
not entitled to receive under the terms of this plan, you may be charged for such services or benefits at
the prevailing rate. If you permit the use of your membership card by any other person, your card may
be retained by this plan, and all your rights under this plan may be terminated.
PLAN SELECTION PERIOD
If your Plan Sponsor offers more than one benefit plan option, you may choose another plan option only
upon your plan's anniversary date. You may select a different plan option by completing a selection
form or application form. Coverage under the new plan option becomes effective on your plan's
anniversary date.
TERMINATING COVERAGE
If you leave your job for any reason or your work hours are reduced below your Plan Sponsor's
minimum requirement, coverage for you and your enrolled family members will end. Coverage ends on
the last day of the last month in which you worked full time. You may, however, be eligible to continue
coverage for a limited time; please see the Continuation section of this Summary Plan Description for
more information.
You can voluntarily discontinue coverage for your enrolled family members at any time by completing a
Termination of Dependent Coverage form and submitting it to your Plan Sponsor. Keep in mind that
once coverage is discontinued, your family members may be subject to the late enrollment waiting
period if they wish to re-enroll later.
Divorced Spouses
If you divorce, coverage for your spouse will end on the last day of the month in which the divorce
decree or legal separation is final. You must notify your Plan Sponsor of the divorce or separation, and
continuation coverage may be available for your spouse. If there are special child custody
circumstances, please contact your Plan Sponsor. Please see the Continuation section for more
information.
Dependent Children
When your enrolled child no longer qualifies as a dependent, coverage will end on the last day
of that month. Please see the Eligibility section of this Summary Plan Description for information
on when your dependent child is eligible beyond age 25. The Continuation section includes
information on other coverage options for those who no longer qualify for coverage.
Dissolution of Domestic Partnership
If you dissolve your domestic partnership, coverage for your domestic partner and their children not
related to you by birth or adoption will end on the last day of the month in which the dissolution of the
domestic partnership is final. You must notify your Plan Sponsor of the dissolution of the domestic
partnership. Under Oregon state continuation laws, a qualified domestic partner and their covered
children may continue this policy's coverage under the same circumstances and to the same extent
afforded an enrolled spouse and their enrolled children (see Oregon Continuation in the Continuation of
Insurance section). Domestic partners and their covered children are not recognized as qualified
beneficiaries under federal COBRA continuation laws. Domestic partners and their covered children
SingleSource Self-Insured 24
Exhibit'A'
may not continue this policy's coverage under COBRA independent of the employee (see COBRA
Continuation in the Continuation of Insurance section).
Certificates of Creditable Coverage
A certificate of creditable coverage is used to verify the dates of your prior health plan coverage
when you apply for coverage under a new policy. These certificates are issued by health
insurers whenever a plan participant's coverage ends. After your or your dependent's coverage
under this plan ends, you will receive a certificate of creditable coverage by mail. PacificSource
has an automated process that generates and mails these certificates whenever coverage ends.
PacificSource will send a separate certificate for any dependents with an effective or termination
date that differs from yours. For questions or requests regarding certificates of creditable
coverage, you are welcome to contact Membership Services Department at (541) 684-5583 or
(866) 999-5583.
CONTINUATION OF INSURANCE
Under federal and state laws, you and your family members may have the right to continue this
plan's coverage for a specified time. You and your dependents may be eligible if:
• Your employment ends or you have a reduction in hours
• You take a leave of absence for military service
• You divorce
• You die
• You become eligible for Medicare benefits if it causes a loss of coverage for your dependents
• Your children no longer qualify as dependents
The following sections describe your rights to continuation under state and federal laws, and
the requirements you must meet to enroll in continuation coverage.
USERRA CONTINUATION
If you take a leave of absence from your job due to military service, you have continuation rights under
the Uniformed Services Employment and Re-employment Rights Act (USERRA).
You and your enrolled family members may continue this plan's coverage if you, the employee, no
longer qualify for coverage under the plan because of military service. Continuation coverage under
USERRA is available for up to 24 months while you are on military leave. If your military service ends
and you do not return to work, your eligibility for USERRA continuation coverage will end. Premium for
continuation coverage is your responsibility.
The following requirements apply to USERRA continuation:
• Family members who were not enrolled in the group plan cannot take continuation. The only
exceptions are newborn babies and newly acquired dependents not covered by another group
health plan.
• To apply for continuation, you must submit a completed Continuation Election Form to your Plan
Sponsorwithin 31 days after the last day of coverage under the group plan.
• You must pay continuation premium to your Plan Sponsor by the first of each month. Your Plan
Sponsorwill include your continuation premium in the group's regular monthly payment.
PacificSource cannot accept the premium directly from you. .
• Your Plan Sponsor must still be self-insured through PacificSource. If your Plan Sponsor
discontinues this plan, you will no longer qualify for continuation.
SingleSource Self-Insured 25
Exhibit'A'
Surviving or Divorced Spouses and QualiFed Domestic Partners
If you die, divorce, or dissolve your qualified domestic partnership, and your spouse or qualified
domestic partner is 55 years or older, your spouse or qualified domestic partner may be able to
continue coverage until eligible for Medicare or other coverage. Dependent children are subject to the
health plan's age and other eligibility requirements. Some restrictions and guidelines apply; please see
your Plan Sponsorfor specific details.
COBRA CONTINUATION
Your Plan Sponsor is subject to the continuation of coverage provisions of the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA) as amended. To find out if you have continuation rights
under COBRA, ask your health plan administrator.
COBRA Eligibility
To be eligible, a member must experience a 'qualifying event' which is an event that causes your
regular group coverage to end and makes you eligible for continuation coverage. When the following
qualifying events happen, you may continue coverage for the lengths of time shown:
Qualifying Event Continuation Period
Employee's termination of employment or reduction in Employee, spouse, and children may continue for up to
hours 18 months'
Employee's divorce or legal separation Souse and children may continue for u to 36 months
Employee's eligibility for Medicare benefits if it causes a Spouse and children may continue for up to 36 months
loss of coverage
Employee's death Souse and children may continue for u to 36 months
Child no longer qualifies as a dependent Child may continue for u to 36 months
Em to er files for Cha ter 11 bankruptcy Only applies to retirees and their covered dependents
If the employee or covered dependent is determined disabled by the Social Security Administration within the first
60 days of continuation coverage, all qualified beneficiaries may continue coverage for up to an additional 11
months, for a total of up to 29 months.
2 The total maximum continuation period is 36 months, even if there is a second qualifying event. A second
qualifying event might be a divorce, legal separation, death, or child no longer qualifying as a dependent after the
employee's termination or reduction in hours.
If your dependents were not covered prior to your qualifying event, they may enroll in the continuation
coverage while you are on continuation. They will be subject to the same rules that apply to active
employees, including the late enrollment waiting period.
If your employment is terminated for gross misconduct, you and your dependents are not eligible for
COBRA continuation.
Domestic partners and their covered children may not continue this policy's coverage under COBRA
independent of the employee.
When Continuation Coverage Ends
Your continuation coverage will end before the end of the continuation period above if any of the
following occur:
• Your continuation premium is not paid on time.
• You become covered under another group health plan that does not exclude or limit treatment for
your pre-existing conditions.
• You become entitled to Medicare benefits.
• Your Plan Sponsor discontinues its health plan and no longer offers a group health plan to any of
its employees.
• Your continuation period was extended from 18 to 29 months due to disability, and you are no
longer considered disabled.
SingleSource Self-Insured 26
Exhibit'A'
Type of Coverage
Under COBRA, you may continue any coverage you had before the qualifying event. If your Plan
Sponsor provides both medical and dental coverage and you were enrolled in both, you may continue
both medical and dental. If your Plan Sponsor provides only one type of coverage, or if you were
enrolled in only one type of coverage, you may continue only that coverage.
COBRA continuation benefits are always the same as your Plan Sponsor's current benefits. Your Plan
Sponsor has the right to change the benefits of its health plan or eliminate the plan entirely. If that
happens, any changes to the group health plan will also apply to everyone enrolled in continuation
coverage.
Your Responsibilities and Deadlines
You must notify your Plan Sponsor within 60 days if you divorce, or if your child no longer qualifies as
a dependent. That will allow your Plan Sponsor to notify you or your dependents of your continuation
rights.
When your Plan Sponsor learns of your eligibility for continuation, your Plan Sponsor will notify you of
your continuation rights and provide a Continuation Election Form. You then have 60 days from that
date or 60 days from the date coverage would otherwise end, whichever is later, to enroll in
continuation coverage by submitting a completed Election Form to your Plan Sponsor. If continuation
coverage is not elected during that 60-day period, coverage will end on the last day of the last month
you were an active employee.
If you do not provide these notifications within the time frames required by COBRA, Plan Sponsors
responsibility to provide coverage under the health plan will end.
Continuation Premium
You or your family members are responsible for the full cost of continuation coverage. The monthly
premium must be paid to your Plan Sponsor. PacificSource cannot accept continuation premium
directly from you. You may make your first premium payment any time within 45 days after you return
your Continuation Election Form to your Plan Sponsor. After the first premium payment, each monthly
payment must reach your Plan Sponsorwithin 30 days of your Plan Sponsors premium due date. If
your Plan Sponsor does not receive your continuation premium on time, continuation coverage will end.
If your coverage is canceled due to a missed payment, it will not be reinstated for any reason. Premium
rates are established annually and may be adjusted if the plan's benefits or costs change.
Keep Your Plan Informed of Address Changes
In order to protect your and your family's rights, you should keep the Plan Sponsor informed of any
changes in your address and the addresses of family members. You should also keep a copy, for your
records, of any notices you send to the Plan Sponsor.
CONTINUATION WHEN YOU RETIRE
If you retire, you and your insured dependents are eligible to continue coverage subject to the following:
• You must apply for continued coverage within 60 days after retirement.
• You must be receiving benefits from PERS (Public Employee Retirement System) or from a similar
retirement plan offered by your Plan Sponsor.
• You will have the same opportunity to switch to another plan during the open enrollment period as
do active employees. If the plan's benefits are changed by the policyholder, your benefits will
change accordingly.
• Except for newly acquired dependents due to marriage, registration of domestic partnership, birth,
or adoption, only your dependents who were covered at the time of retirement may continue
coverage under this provision. You may add a new spouse, domestic partner, or other newly
acquired dependent after retirement if family coverage is available. A completed enrollment
application must be submitted within 31 days of the date of marriage, registration of domestic
partnership, birth, or adoption.
SingleSource Self-Insured 27
Exhibit'A'
Your continuation coverage will end when any one of the following occurs:
• When full premium is not paid or when your coverage is voluntarily terminated, your coverage will
end on the last day of the month for which premium was paid.
• When you become eligible for Medicare coverage, your coverage will end on the last day of the
month preceding Medicare eligibility.
• When the regular group policy is terminated, your coverage will end on the date of termination.
Your dependent's continuation coverage will end when any one of the following occurs:
• When full premium for the dependent is not paid or when the dependent's coverage is voluntarily
terminated by you or your dependent, coverage will end on the last day of the month for which
premium was paid.
• When your dependent becomes eligible for Medicare coverage, your dependent's coverage will end
on the last day of the month preceding Medicare eligibility.
• When you die, divorce, or dissolve your domestic partnership, your dependent's coverage will end
on the last day of the month following the death, divorce, or dissolution of the domestic partnership.
• When your dependent is otherwise no longer considered a dependent under the group plan, his or
her coverage will end on the last day of the month of their eligibility. Continuation of coverage may
be available under COBRA continuation (see Continuation of Coverage provisions).
• When the regular group policy is terminated, your dependent's coverage will end on the date of
termination.
WORK STOPPAGE
Labor Unions
If you are a union member, you have certain continuation rights in the event of a labor strike. Your
union is responsible for collecting your premium and can answer questions about coverage during the
strike.
EXTENSION OF BENEFITS
If you are on a Plan Sponsor-approved non-FMLA leave of absence, you may continue coverage under
active status for up to three months by self pay to the Plan Sponsor. Absences extending beyond three
months will be subject to the Continuation of Insurance provisions of this plan.
COVERED EXPENSES
This plan provides comprehensive medical coverage when care is medically necessary to treat an
illness or injury. Be careful -just because a treatment is prescribed by a healthcare professional does
not mean it is medically necessary under the terms of the plan. Also remember that just because a
service or supply is a covered benefit under this plan does not necessarily mean all billed charges will
be paid.
Some medically necessary services and supplies may be excluded from coverage under this plan. Be
sure you read and understand the Benefit Limitations and Exclusions section of this book, including the
section on Preauthorization. If you ever have a question about your plan benefits, contact the
PacificSource Customer Service Department.
Medical Necessity
Except for specified Preventive Care services, the benefits of this health plan are paid only toward the
covered expense of medically necessary diagnosis or treatment of illness or injury. This is true even
though the service or supply is not specifically excluded. All treatment is subject to review for medical
necessity. Review of treatment may involve prior approval, concurrent review of the continuation of
treatment, post-treatment review or any combination of these. For additional information, see 'medically
necessary' in the Definitions section of this Summary Plan Description.
SingleSource Self-Insured 28
Exhibit'A'
Be careful. Your healthcare provider could prescribe services or supplies that are not covered under
this plan. Also, just because a service or supply is a covered benefit does not mean all related charges
will be paid.
Healthcare Providers
This plan provides benefits only for covered expenses and supplies rendered a physician (M.D. or
O.D.), practitioner, nurse, hospital or specialized treatment facility, durable medical equipment supplier,
or other licensed medical provider as specifically stated in this Summary Plan Description. The services
or supplies provided by individuals or companies that are not specified as eligible practitioners are not
eligible for reimbursement under the benefits of this plan. For additional information, see 'practitioner',
'specialized treatment facility', and 'durable medical equipment supplier' in the Definitions section of this
Summary Plan Description.
Your Annual Deductible
Deductible Carryover. The deductible must be satisfied only once in any benefit year, even though
there may be several conditions treated. Covered expenses incurred during the last three (3) months of
the previous benefit year will be applied to the subsequent year's benefit year deductible subject to the
following:
• The covered expenses were applied to the deductible;
• The covered expenses were incurred during the last three (3) months of the year; and
• The prior year's deductible was not satisfied.
Final determination of which expenses apply to the deductible will be based on the order in which
charges are incurred, even if bills for charges are not received in that order.
Your Annual Out-of-Pocket Limit
This plan has an out-of-pocket limit provision to protect you from excessive medical expenses. The
Medical Benefit Summary shows your plan's annual out-of-pocket limits for participating and/or
nonparticipating providers. If you incur covered expenses over those amounts, this plan will pay 100
percent of eligible charges, subject to the allowable fee.
Your expenses for the following do not count toward the annual out-of-pocket limit:
• Charges applied to deductible, if applicable to your plan
• Co-payments, if applicable to your plan
• Prescription drugs
• Charges over the allowable fee for services of non-participating providers
• Incurred charges that exceed amounts allowed under this plan
Charges over the allowable fee for services of non-participating providers, and incurred charges that
exceed amounts allowed under this plan, and co-payments will continue to be your responsibility even
after the out-of-pocket or stop-loss limit is reached.
Prescription drug benefits are not affected by the out-of-pocket or stop-loss limit. You will still be
responsible for that co-payment or co-insurance payment even after the out-of-pocket or stop-loss limit
is reached.
MEDICAL BENEFITS
About Your Medical Benefits
All benefits provided under this plan must satisfy some basic conditions. The following conditions are
commonly included in health benefit plans but are often overlooked or misunderstood.
SingleSource Self-Insured 29
Exhibit'A'
Medical Necessity - The plan provides benefits only for covered services and supplies that are
medically necessary for the treatment of a covered illness or injury. Be careful-just because a
treatment is prescribed by a healthcare professional does not necessarily mean it is medically
necessary as defined by the plan. And, some medically necessary services and supplies may be
excluded from coverage. Also, the treatment must not be experimental and/or investigational.
Allowable Fees - The plan provides benefits only for covered expenses that are equal to or less than
the allowable amount, as defined by the plan, in the geographic area where services or supplies are
provided. Any amounts that exceed the allowable amount are not recognized by the plan for any
purpose.
Health Care Provider - The plan provides benefits only for covered expenses and supplies rendered
by a physician, practitioner, nurse, hospital or specialized treatment facility, durable medical equipment
supplier, or other licensed medical provider as specifically stated in this plan summary. The services or
supplies provided by individuals or companies that are not specified as eligible practitioners are not
eligible for reimbursement under the benefits of this plan. For additional information, see practitioner,
specialized treatment facility, and durable medical equipment in the Definitions section of this
document.
Custodial Care Providers - The plan does not provide benefits for services and supplies that are
furnished primarily to assist an individual in the activities of daily living. Activities of daily living include
such things as bathing, feeding, administration of oral medications, academic, social, or behavior skills
training, and other services that can be provided by persons without the training of a health care
practitioner.
Benefit Year- The word year, as used in this document, refers to the benefit year, which is the 12-
month period beginning January 1 and ending December 31. Unless otherwise specified, all annual
benefit maximums and deductibles accumulate during the benefit year.
Deductibles - A deductible is the amount of covered expenses you must pay during each year before
the plan will consider expenses for reimbursement. The individual deductible applies separately to each
covered person. The family deductible applies collectively to all covered persons in the same family.
When the family deductible is satisfied, no further deductible will be applied for any covered family
member during the remainder of the year. The annual individual and family deductible amounts are
shown on the Medical Benefit Summary.
Benefit Percentage Payable - Benefit percentage payable represents the portion of covered
expenses paid by the plan after you have satisfied any applicable deductible. These percentages apply
only to covered expenses which do not exceed the allowable amount. You are responsible for all
remaining covered and non-covered expenses, including any amount that exceeds the allowable
amount for covered services. The benefit percentages payable are shown on the Medical Benefit
Summary.
Copayments - Copayments are the first-dollar amounts you must pay for certain covered services,
which are usually paid at the time the service is performed (i.e. physician office visits or emergency
room visits). These copayments do not apply to your annual deductible or out-of-pocket maximum,
unless otherwise specified on the Medical Benefit Summary. The copayment amounts are shown on
the Medical Benefit Summary.
Out-Of-Pocket Maximum(s) -An out-of-pocket maximum is the maximum amount of covered
expenses you must pay during a year, before the plan's benefit percentage payable increases. The
individual out-of-pocket maximum applies separately to each covered person. When a covered person
reaches the annual out-of-pocket maximum, the plan will pay 100% of additional covered expenses for
that individual during the remainder of that year, subject to the lifetime maximum amount, if applicable.
However, expenses for services which do not apply to the out-of-pocket maximum will never be paid at
100%. The annual individual and family out-of-pocket maximum amounts are shown on the Medical
Benefit Summary.
Benefit Maximums - Total plan payments for each covered person are limited to certain maximum
benefit amounts. A benefit maximum can apply to specific benefit categories or to all benefits. A benefit
maximum amount may also apply to a specific time period, such as annual.
SingleSource Self-Insured 30
Exhibit 'A'
Least Costly Setting For Services - Benefits of the plan provide for reimbursement of covered
services performed in the least costly setting where services can be safely provided. If a procedure can
be done safely in an outpatient setting but is performed in a hospital inpatient setting, this plan will only
pay what it would have paid for the procedure on an outpatient basis. If services are performed in an
inappropriate setting, your benefits may be reduced.
PLAN BENEFITS
This plan provides benefits for the following services and supplies as outlined on your Medical Benefit
Summary. These services and supplies may require you to satisfy a deductible, make a co-payment, or
both, and they may be subject to additional limitations or maximum dollar amounts. For a medical
expense to be eligible for payment, you must be covered under this plan on the date the expense is
incurred. Please refer to your Medical Benefit Summary and the Benefit Limitations and Exclusions
section of this Summary Plan Description for more information.
Accident Benefit
In the event of an injury caused by an accident the plan benefit will be as follows:
The balance is covered as stated in your Medical Benefit Summary for covered expense.
'Accident' means an unforeseen or unexpected event causing injury which requires medical attention.
'Injury' means bodily trauma or damages which is independent of disease or infirmity. The damage
must be caused solely through external and accidental means. For the purpose of this benefit, injury
does not include musculoskeletal sprains or strains obtained in the performance of physical activity.
PREVENTIVE CARE SERVICES
This plan covers the following preventive care services when provided by a physician, physician
assistant, or nurse practitioner:
• Routine physicals for members age 22 and older according to the following schedule:
- Ages 22 and over One exam every benefit year
Only laboratory work tests and other diagnostic testing procedures related to the routine physical
exam are covered by this benefit. Any laboratory tests and other diagnostic testing procedures
ordered during, but not related to, a routine physical examination are not covered by this
preventative care benefit. Please see Outpatient Services in this section.
• Well woman visits, including the following:
- One routine gynecological exam each benefit year for women 18 and over. Exams may
include Pap smear, pelvic exam, breast exam, blood pressure check, and weight check. Exams
may also include an annual mammogram for women over the age of 40, once between the
ages of 35-40 unless medically necessary, for the purpose of early detection. Covered lab
services are limited to occult blood, urinalysis, and complete blood count.
- Routine preventive mammograms for women as recommended.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Preventive Care - Well Woman Visits' applies.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Outpatient Services - Diagnostic and Therapeutic Radiology and Lab'
applies to diagnostic mammograms related to the ongoing evaluation or treatment of a
medical condition.
- Pelvic exams and Pap smear exams at any time upon referral of a women's healthcare
provider; and pelvic exams and Pap smear exams annually for women 18 to 64 years of age
with or without a referral from a women's healthcare provider.
- Breast exams annually for women 18 years of age or older or at any time when recommended
by a women's healthcare provider for the purpose of checking for lumps and other changes for
early detection and prevention of breast cancer.
• Colorectal cancer screening exams and lab work including the following:
SingleSource Self-Insured 31
Exhibit 'A'
A fecal occult blood test once per benefit year
A flexible sigmoidoscopy every five benefit years
A colonoscopy for age 50+ every ten benefit years
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Preventive Care - Routine Colonoscopy' applies.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for 'Professional Services - Surgery' and for'Outpatient Services -
Outpatient Surgery/Services' apply to colonoscopies related to ongoing evaluation or
treatment of a medical condition.
A double contrast barium enema every five benefit years
• Prostate cancer screening, every two benefit years. Exams may include a digital rectal
examination and a prostate-specific antigen test. Screenings apply to outpatient surgery/services
benefit regardless of whether they are preventive or diagnostic.
• Well baby/well child care exams for members age 21 and younger according to the following
schedule:
- At birth: One standard in-hospital exam
- Ages 0 - 2: 12 additional exams during first 36 months of life
- Ages 3 - 21: One exam per benefit year
Newborn circumcision is a covered benefit even if performed several days after birth. Only
laboratory tests and other diagnostic testing procedures related to a well baby/child care exam are
covered by this plan. Any laboratory tests and other diagnostic testing procedures ordered during,
but not related to, a well baby/child care exam are not covered by this preventative care benefit.
Please see Outpatient Services in this section.
• Standard age-appropriated childhood and adult immunizations for primary prevention of infectious
diseases as recommended by and adopted the Centers for Disease Control and Prevention,
American Academy of Pediatrics, American Academy of Family Physicians, or similar standard-
setting body. Benefits do not include immunizations for more elective, investigative, unproven, or
discretionary reasons (e.g. travel). Covered immunizations include, but may not be limited to the
following:
- Diphtheria, pertussis, and tetanus (DPT) vaccines, given separately or together
- Hemophilus influenza B vaccine
- Hepatitis A vaccine
- Hepatitis B vaccine
Human papillomavirus (HPV) vaccine
- Influenza vaccine
- Measles, mumps, and rubella (MMR) vaccines, given separately or together
- Meningococcal (meningitis) vaccine
- Pneumococcal vaccine
- Polio vaccine
- Varicella (chicken pox) vaccine
• Tobacco use cessation program services are covered only when provided by a PacificSource
approved program. Approved programs are covered at 100% of the cost up to a maximum lifetime
benefit of two quit attempts. Approved programs are limited to members age 15 or older. Specific
nicotine replacement therapy will only be covered according to the program's description. If this
policy includes benefits for prescription drugs, tobacco use cessation related medication prescribed
in conjunction with an approved tobacco use cessation program will be covered to the same extent
this policy covers other prescription medications.
PROFESSIONAL SERVICES
This plan covers the following professional services when medically necessary:
SingleSource Self-Insured 32
Exhibit'A'
• Services of a physician (M.D. or D.O.) for diagnosis or treatment of illness or injury
• Services of a licensed physician assistant under the supervision of a physician
• Services of a certified surgical assistant, surgical technician, or registered nurse (R.N.) when
providing medically necessary services as a surgical first assistant during a covered surgery
• Services of a nurse practitioner, including certified registered nurse anesthetist (C.R.N.A.) and
certified nurse midwife (C.N.M.), for medically necessary diagnosis or treatment of illness or injury
• Urgent care services provided by a physician. Urgent care is unscheduled medical care for an
illness, injury, or disease that a prudent lay person would consider not life-threatening and treatable
at urgent care. Examples of urgent care situations include sprains, cuts, and illnesses that do not
require immediate medical attention in order to prevent seriously damaging the health of the
person.
• Outpatient rehabilitative services provided by a licensed physical therapist, occupational
therapist, speech language pathologist, physician, or other practitioner licensed to provide physical,
occupational, or speech therapy. Services must be prescribed in writing by a licensed physician,
dentist, podiatrist, nurse practitioner, or physician assistant. The prescription must include site,
modality, duration, and frequency of treatment. Total covered expenses for outpatient rehabilitative
services is limited to a combined maximum of 30 visits per benefit year subject to preauthorization
and concurrent review by PacificSource for medical necessity. Only treatment of neurologic
conditions (e.g. stroke, spinal cord injury, head injury, pediatric neurodevelopmental problems, and
other problems associated with pervasive developmental disorders for which rehabilitative services
would be appropriate for children under 18 years of age) may be considered for additional benefits,
not to exceed 30 visits per condition, when criteria for supplemental services are met.
• Services for speech therapy will only be allowed when needed to correct stuttering, hearing loss,
peripheral speech mechanism problems, and deficits due to neurological disease or injury. Speech
and/or cognitive therapy for acute illnesses and injuries are covered up to one year post injury
when the services do not duplicate those provided by other eligible providers, including
occupational therapists or neuropsychologists.
• Outpatient pulmonary rehabilitation programs are covered when prescribed by a physician for
patients with severe chronic lung disease that interferes with normal daily activities despite optimal
medication management.
• For related provisions, see 'motion analysis', 'vocational rehabilitation', and 'speech therapy' under
'Excluded Services - Types of Treatments' in the Benefit Limitations and Exclusions section of this
Summary Plan Description.
• Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to
the same payment amounts, conditions, and limitations that apply to similar expenses for illness,
except that pregnancy is not considered a pre-existing condition.
Please contact the PacificSource Customer Service Department as soon as you learn of your
pregnancy. PacificSource's staff will explain your plan's maternity benefits and help you enroll in
PacificSource's free prenatal care program.
• Routine nursery care of a newborn while the mother is hospitalized and eligible for pregnancy-
related benefits under this plan if the newborn is also eligible and enrolled in this plan.
• Services of a licensed audiologist for medically necessary audiological (hearing) tests.
• Services of a dentist or physician to treat injury of the jaw or natural teeth. Services must be
provided within 18 months of the injury. Except for the initial examination, services for treatment of
an injury to the jaw or natural teeth require preauthorization to be covered.
• Services of a dentist or physician for orthognathic (jaw) surgery as follows:
- When medically necessary to repair an accidental injury. Services must be provided within
one year after the accident.
- For removal of a malignancy, including reconstruction of the jaw within one year after that
surgery
• Services of a board-certified or board-eligible genetic counselor when referred by a physician or
nurse practitioner for evaluation of genetic disease
SingleSource Self-Insured 33
Exhibit'A'
• Medically necessary telemedical health services for health services covered by this plan when
provided in person by a healthcare professional when the telemedical health service does not
duplicate or supplant a health service that is available to the patient in person. The location of the
patient receiving telemedical health services may include, but is not limited to: hospital; rural health
clinic; federally qualified health center; physician's office; community mental health center; skilled
nursing facility; renal dialysis center; or site where public health services are provided. Coverage of
telemedical health services are subject to the same deductible, co-payment, or co-insurance
requirements that apply to comparable health services provided in person.
HOSPITAL AND SKILLED NURSING FACILITY SERVICES
This plan covers medically necessary hospital inpatient services. Charges for a hospital room are
covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer
semi-private rooms). Charges for a private room are covered if the attending physician orders
hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary
isolation. Coverage includes eligible services provided by a hospital owned or operated by the state of
Oregon, or any state approved mental health and developmental disabilities program.
In addition to the hospital room, covered inpatient hospital services may include (but are not limited to):
• Cardiac care unit
• Operating room
• Anesthesia and post-anesthesia recovery
• Respiratory care
• Inpatient medications
• Lab and radiology services
• Dressings, equipment, and other necessary supplies
The plan does not cover charges for rental of telephones, radios, or televisions, or for guest meals or
other personal items.
Services of a skilled nursing facility and convalescent homes are covered for up to 120 days per
benefit year when preauthorized by PacificSource. Services must be medically necessary. Confinement
for custodial care is not covered.
Inpatient rehabilitative services are covered up to a maximum of 50 days of rehabilitative care per
benefit year, except that treatment for head or spinal cord injuries is covered for up to 60 days per
benefit year. Recreation therapy is only covered as part of an inpatient rehabilitation admission.
Services must be preauthorized by PacificSource
OUTPATIENT SERVICES
This plan covers the following outpatient care services:
• Advanced diagnostic imaging procedures that are medically necessary for the diagnosis of
illness or injury. For purposes of this benefit, advanced diagnostic imaging procedures include CT
scans, MRIs, PET scans, CATH labs and nuclear cardiology studies. When services are provided
as part of a covered emergency room visit, your plan's emergency room benefit applies. In all other
situations and settings, benefits are subject to the deductibles, co-payments, and/or co-insurance
stated in your Medical Benefit Summary for Outpatient Services - Advanced Diagnostic Imaging.
• Diagnostic radiology and laboratory procedures provided or ordered by a physician, nurse
practitioner, or physician assistant. These services may be performed or provided by laboratories,
radiology facilities, hospitals, and physicians, including services in conjunction with office visits.
SingleSource Self-Insured 34
Exhibit 'A'
• Benefits for members who are receiving services for end-stage renal disease (ESRD) who are
eligible for Medicare, are limited to 125% of the current Medicare allowable amount for participating
and nonparticipating ESRD service providers. Benefits will continue to be paid at the cost share
level applied to other benefits in the same category for members who are not eligible for Medicare.
PacificSource will contact members when the first ESRD preauthorization request is received to
assist the member in understanding their out-of-pocket expenses and care plan.
• Emergency room services. The emergency room co-payment stated in your Medical Benefit
Summary covers medical screening and any diagnostic tests needed for emergency care, such as
radiology, laboratory work, CT scans, and MRIs. The co-payment does not cover further treatment
provided on referral from the emergency room.
In true medical emergencies, non-participating providers are paid at the participating provider level.
Emergency room charges for services, supplies, or conditions excluded from coverage under this
plan are not eligible for payment. That includes conditions subject to the plan's exclusion periods
for pre-existing and other conditions. Please see the Benefit Limitations and Exclusions section of
this Summary Plan Description.
• Surgery and other outpatient services. Benefits are based on the setting where services are
performed.
- For surgeries or outpatient services performed in a physician's office, the benefit stated in
your Medical Benefit Summary for Professional Services - Office Procedures and Supplies
applies.
- For surgeries or outpatient services performed in an ambulatory surgical center or
outpatient hospital setting, both the benefits stated in your Medical Benefit Summary for
Professional Services - Surgery and the Outpatient Services -Outpatient Surgery/Services
apply.
• Therapeutic radiology services, chemotherapy, and renal dialysis provided or ordered by a
physician. Covered services include a prescribed, orally administered anticancer medication used
to kill or slow the growth of cancerous cells.
• Other medically necessary diagnostic services provided in a hospital or outpatient setting,
including testing or observation to diagnose the extent of a medical condition.
EMERGENCY SERVICES
In a true medical emergency, this plan covers services and supplies necessary to determine the nature
and extent of the emergency condition and to stabilize the patient.
An emergency medical condition is an injury or sudden illness, including severe pain, so severe that a
prudent layperson with an average knowledge of health and medicine would expect that failure to
receive immediate medical attention would risk seriously damaging the health of a person or fetus in the
case of a pregnant woman. Examples of emergency medical conditions include (but are not limited to):
• Unusual or heavy bleeding
• Sudden abdominal or chest pains
• Suspected heart attacks
• Major traumatic injuries
• Serious burns
• Poisoning
• Unconsciousness
• Convulsions or seizures
• Difficulty breathing
• Sudden fevers
SingleSource Self-Insured 35
Exhibit 'A'
If you need immediate assistance for a medical emergency, call 911. If you have an emergency
medical condition, you should go directly to the nearest emergency room or appropriate facility. Care
for a medical emergency is covered at the participating provider percentage stated in your Medical
Benefit Summary even if you are treated at a non-participating hospital.
If you are admitted to a non-participating hospital after your emergency condition is stabilized, your Plan
Sponsor may require you to transfer to a participating facility in order to continue receiving benefits at
the participating provider level.
Maternity Services
Maternity means, in any one pregnancy, all prenatal services including complications and miscarriage,
delivery, postnatal services provided within six months of delivery, and routine nursery care of a
newborn child. Maternity services are covered subject to the deductible, co-payments, and/or co-
insurance stated in your Medical Benefit Summary regardless of marital status.
• Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to
the same payment amounts, conditions, and limitations that apply to similar expenses for illness.
• Please contact the PacificSoume Customer Service Department as soon as you learn of your
pregnancy. PacificSource's staff will explain your plan's matemity benefits and help you enroll in
PacificSource's free prenatal care program.
• This plan provides routine nursery care of a newborn while the mother is hospitalized and eligible
for pregnancy-related benefits under this plan if the newborn is also eligible and enrolled in this
plan, regardless of marital status.
Special Information about Childbirth- This plan covers hospital inpatient services for childbirth
according to the Newborns' and Mothers' Health Protection Act of 1996. This plan does not restrict the
length of stay for the mother or newborn child to less than 48 hours after vaginal delivery, or to less
than 96 hours after Cesarean section delivery. Your provider is allowed to discharge you or your
newborn sooner than that, but only if you both agree. For childbirth, your provider does not need to
preauthorize your hospital stay with PacificSource.
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES
This plan covers medically necessary crisis intervention, diagnosis, and treatment of mental health
conditions and chemical dependency. Refer to the Benefit Limitations and Exclusions section of this
Summary Plan Description for more information on services not covered by your plan.
Mental Health and Chemical Dependency Services
It is the intent of this plan to comply with all existing regulations of Mental Health Parity and Addiction
Equity Act of 2008 (MHPAEA). If for some reason the information presented in the plan differs from the
actual regulations of the MHPAEA, the plan reserves the right to administer the plan in accordance with
such actual regulations.
Providers Eligible for Reimbursement
A mental and/or chemical healthcare provider (see Definitions section of this Summary Plan
Description) is eligible for reimbursement if:
• The mental and/or chemical healthcare provider is approved by the Oregon Department of Human
Services;
• The mental and/or chemical healthcare provider is accredited for the particular level of care for
which reimbursement is being requested by the Oregon Joint Commission on Accreditation of
Hospitals or the Commission on Accreditation of Rehabilitation Facilities; or
• The patient is staying overnight at the mental and/or chemical healthcare facility (see Definitions
section of this Summary Plan Description) and is involved in a structured program at least eight
hours per day, five days per week; or
• The mental and/or chemical healthcare provider is providing a covered benefit under this policy,
and
SingleSource Self-Insured 36
Exhibit 'A'
Eligible mental and/or chemical healthcare providers are:
• A program licensed, approved, established, maintained, contracted with, or operated by the
Addictions and Mental Health Division of the Oregon Health Authority;
• A medical or osteopathic physician licensed by the State Board of Medical Examiners;
• A psychologist (Ph.D.) licensed by the State Board of Psychologists' Examiners;
• A nurse practitioner registered by the State Board of Nursing;
• A clinical social worker (L.C.S.W.) licensed by the State Board of Clinical Social Workers;
• A Licensed Professional Counselor (L.P.C) licensed by the State Board of Licensed Professional
Counselors and Therapists;
• A Licensed Marriage and Family Therapist (L.M.F.T) licensed by the State Board of Licensed
Professional Counselors and Therapists; and
• A hospital or other healthcare facility licensed by the Joint Commission on Accreditation of
Hospitals or the Commission on Accreditation of Rehabilitation Facilities for inpatient or residential
care and treatment of mental health conditions and/or chemical dependency.
Medical Necessity and Appropriateness of Treatment
• As with all medical treatment, mental health and chemical dependency treatment is subject to
review for medical necessity and/or appropriateness. Review of treatment may involve pre-service
review, concurrent review of the continuation of treatment, post-treatment review, or a combination
of these. PacificSource will notify the patient and patient's provider when a treatment review is
necessary to make a determination of medical necessity.
• A second opinion may be required for a medical necessity determination. PacificSource will notify
the patient when this requirement is applicable.
• PacificSource must be notified of an emergency admission within two business days.
• Medication management by an M.D. (such as a psychiatrist) does not require review.
• Treatment of substance abuse and related disorders is subject to placement criteria established by
the American Society of Addiction Medicine.
Mental Health Parity and Addiction Equity Act of 2008
This group health plan complies with all federal laws and regulations related to the Mental Health Parity
and Addiction Equity Act of 2008.
HOME HEALTH AND HOSPICE SERVICES
• This plan covers home health services up to 180 visits per benefit year when preauthorized by
PacificSource. Covered services include skilled nursing by a R.N. or L.P.N.; physical, occupational,
and speech therapy; and medical social work services provided by a licensed home health agency.
Private duty nursing is not covered.
• Home infusion services are covered when preauthorized by PacificSource. This benefit covers
parenteral nutrition, medications, and biologicals (other than immunizations) that cannot be self-
administered. Benefits are paid at the percentage stated in your Medical Benefit Summary for home
health care.
• This plan covers hospice services when preauthorized by PacificSource. Hospice services are
intended to meet the physical, emotional, and spiritual needs of the patient and family during the
final stages of illness and dying„while maintaining the patient in the home setting. Services are
intended to supplement the efforts of an unpaid caregiver. Hospice benefits do not cover services
of a primary caregiver such as a relative or friend, or private duty nursing. PacificSource uses the
following criteria to determine eligibility for hospice benefits:
- The member's physician must certify that the member is terminally ill with a life expectancy of
less than six months;
- The member must be living at home;
- A non-salaried primary caregiver must be available and willing to provide custodial care to the
member on a daily basis; and
SingleSource Self-Insured 37
Exhibit'A'
The member must not be undergoing treatment of the terminal illness other than for direct
control of adverse symptoms.
Only the following hospice services are covered:
- Home nursing visits.
Home health aides when necessary to assist in personal care.
- Home visits by a medical social worker.
- Home visits by the hospice physician.
- Prescription medications for the relief of symptoms manifested by the terminal illness.
- Medically necessary physical, occupational, and speech therapy provided in the home.
Home infusion therapy.
- Durable medical equipment, oxygen, and medical supplies.
- Respite care provided in a nursing facility to provide relief for the primary caregiver, subject to a
maximum of five consecutive days and to a lifetime maximum benefit of 30 days. A member
must be enrolled in a hospice program to be eligible for respite care benefits.
- Inpatient hospice care when provided by a Medicare-certified or state-certified program when
admission to an acute care hospital would otherwise be medically necessary.
- Pastoral care and bereavement services.
The member retains the right to all other services provided under this contract, including active
treatment of non-terminal illnesses, except for services of another provider that duplicate the services of
the hospice team.
DURABLE MEDICAL EQUIPMENT
• This plan covers prosthetic and orthotic devices that are medically necessary to restore or
maintain the ability to complete activities of daily living or essential job-related activities and that are
not solely for comfort or convenience. Benefits include coverage of all services and supplies
medically necessary for the effective use of a prosthetic or orthotic device, including formulating its
design, fabrication, material and component selection, measurements, fittings, static and dynamic
alignments, and instructing the patient in the use of the device. Benefits also include coverage for
any repair or replacement of a prosthetic or orthotic device that is determined medically necessary
to restore or maintain the ability to complete activities of daily living or essential job-related activities
and that is not solely for comfort or convenience.
• This plan covers durable medical equipment prescribed exclusively to treat medical conditions.
Covered equipment includes crutches, wheelchairs, orthopedic braces, home glucose meters,
equipment for administering oxygen, and non-power assisted prosthetic limbs and eyes. Durable
medical equipment must be prescribed by a licensed M.D., D.O., N.P., P.A., D.D.S., D.M.D., or
D.P.M. to be covered. This plan does not cover equipment commonly used for nonmedical
purposes, for physical or occupational therapy, or prescribed primarily for comfort. Please see
'Excluded Services - Equipment and Devices' in the Benefit Limitations and Exclusions section for
information on items not covered. The following limitations apply to durable medical equipment:
- This benefit covers the cost of either purchase or rental of the equipment for the period
needed, whichever is less. Repair or replacement of equipment is also covered when
necessary, subject to all conditions and limitations of the plan. If the cost of the purchase,
rental, repair, or replacement is over $800, preauthorization by PacificSource is required.
- Only expenses for durable medical equipment, or prosthetic and orthotic devices that are
provided by a PacificSource contracted provider or a provider that satisfies the criteria of
the Medicare fee schedule for Suppliers of Durable Medical Equipment, Prosthetics,
Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description
are eligible for reimbursement. Mail order or Internet/Web based providers are not eligible
providers.
- Purchase, rental, repair, lease, or replacement of a power-assisted wheelchair (including
batteries and other accessories) requires preauthorization by PacificSource and is payable
only in lieu of benefits for a manual wheelchair.
SingleSource Self-Insured 38
Exhibit'A'
The durable medical equipment benefit also covers lenses to correct a specific vision
defect resulting from a severe medical or surgical problem, such as stroke, neurological
disease, trauma, or eye surgery other than refraction procedures. Coverage is subject to
the following limitations:
o The medical or surgical problem must cause visual impairment or disability due to loss
of binocular vision or visual field defects (not merely a refractive error or astigmatism)
that requires lenses to restore some normalcy to vision.
o The maximum allowance for glasses (lenses and frames), or contact lenses in lieu of
glasses, is limited to $200 per initial case. 'Initial case' is defined as the first time
surgery or treatment is performed on either eye. Other policy limitations, such as
exclusions for extra lenses, other hardware, tinting of lenses, eye exercises, or vision
therapy, also apply.
o Benefits for subsequent medically necessary vision corrections to either eye (including
an eye not previously treated) are limited to the cost of lenses only.
Reimbursement is subject to the deductible, co-payment, and/or co-insurance stated in
your Medical Benefit Summary for durable medical equipment and is in lieu of, and not in
addition to benefits payable under any vision endorsement that may be added to this plan.
The durable medical equipment benefit also covers hearing aids for members under 18
years of age and younger, or 25 years of age and younger if the member is enrolled in a
secondary school or an accredited educational institution. Coverage is limited to a
maximum benefit of $4,000 every 48 months. The benefit amount may be adjusted on
January 1 of each year to reflect the U.S City Average Consumer Price Index.
Medically necessary treatment for sleep apnea and other sleeping disorders is covered
when preauthorized by PacificSource. Coverage of oral devices includes charges for
consultation, fitting, adjustment, follow-up care, and the appliances , is limited to a lifetime
maximum benefit of $500, including charges for consultation, fitting, adjustment, follow-up
care, and the appliance.. The appliance must be prescribed by a physician specializing in
evaluation and treatment of obstructive sleep apnea, and the condition must meet criteria
for obstructive sleep apnea.
Wigs following chemotherapy or radiation therapy are covered up to a maximum benefit of
$150 per benefit year.
Breastfeeding pumps, manual and electric, are covered at no cost per pregnancy when
purchased or rented from a licensed provider, or purchased from a retail outlet. Hospital-
grade breast pumps are excluded under preventive care and regular benefits.
TRANSPLANT SERVICES
This plan covers certain medically necessary organ and tissue transplants. It also covers the cost of
acquiring organs or tissues needed for covered transplants and limited travel expenses for the patient,
subject to certain limitations.
All pretransplant evaluations, services, treatments, and supplies for transplant procedures require
preauthorization by PacificSource.
You must have been covered under this plan for at least 24 consecutive months or since birth to be
eligible for transplant benefits, including benefits for transplantation evaluation. See Exclusion Periods -
Transplants in the Benefit Limitations and Exclusions section of this Summary Plan Description for
details.
This plan covers the following medically necessary organ and tissue transplants:
• Kidney
• Kidney - Pancreas
• Pancreas whole organ transplantation (under certain criteria)
• Heart
• Heart - Lung
SingleSource Self-Insured 39
Exhibit 'A'
• Lung
• Liver (under certain criteria)
• Bone marrow and peripheral blood stem cell
• Pediatric bowel
This plan only covers transplants of human body organs and tissues. Transplants of artificial, animal, or
other non-human organs and tissues are not covered.
Expenses for the acquisition of organs or tissues for transplantation are covered only when the
transplantation itself is covered under this contract, and is subject to the following limitations:
• Testing of related or unrelated donors for a potential living related organ donation is payable at the
same percentage that would apply to the same testing of an insured recipient.
• Expense for acquisition of cadaver organs is covered, payable at the same percentage and subject
to the same maximum dollar limitation, if any, as the transplant itself.
• Medical services required for the removal and transportation of organs or tissues from living donors
are covered. Coverage of the organ or tissue donation is at the same percentage payable for the
transplant itself up to $8,000 if the donor is a member of this plan, and applies to the maximum
dollar limitation for the transplant, if any.
- If the donor is not a PacificSource member, only those complications of the donation that occur
during the initial hospitalization are covered, and such complications are covered only to the
extent that they are not covered by another health plan or government program. Coverage is at
the same percentage payable for the transplant itself, and also applies to the maximum dollar
limitation, if any, for the transplant.
- If the donor is a PacificSource member, complications of the donation are covered as any other
illness would be covered.
• Transplant related services, including HLA typing, sibling tissue typing, and evaluation costs, are
considered transplant expenses and accumulate toward any transplant benefit limitations and are
subject to PacificSource's provider contractual agreements (see Payment of Transplant Benefits,
below).
Travel and housing expenses for the recipient are limited to $5,000 per transplant. Travel and living
expenses are not covered for the donor.
Payment of Transplant Benefits
If a transplant is performed at a participating Center of Excellence transplantation facility, covered
charges of the facility are subject to plan deductibles (co-insurance and co-payment amounts after
deductible are waived). If PacificSource's contract with the facility includes the services of the medical
professionals performing the transplant (such as physicians, nurses, and anesthesiologists), those
charges are also subject to plan deductibles (co-insurance and co-payment amounts after deductible
are waived). If the professional fees are not included in PacificSource's contract with the facility, then
those benefits are provided according to your Medical Benefit Summary.
If transplant services are available through a contracted transplantation facility but are not performed at
a contracted facility, you are responsible for satisfying any deductibles or co-payments stated in your
Medical Benefit Summary. This plan then pays at of 60% of the UCR after deductible and co-payments.
Services of non-participating medical professionals are paid at the non-participating provider benefit
level percentages and do not apply to the out-of-pocket maximum.
OTHER COVERED SERVICES, SUPPLIES, AND
TREATMENTS
• This plan covers services of a state certified ground or air ambulance when private transportation
is medically inappropriate because the acute medical condition requires paramedic support.
Benefits are provided for emergency ambulance service and/or transport to the nearest facility
capable of treating the condition. Air ambulance service is covered only when ground transportation
is medically or physically inappropriate. Reimbursement to nonparticipating air ambulance services
are based on 125% of the Medicare allowance. In some cases Medicare allowance may be
SingleSource Self-Insured 40
Exhibit 'A'
significantly lower than the provider's billed amount. The provider may hold you responsible for the
amount they bill in excess of the Medicare allowance, as well as applicable deductibles and
coinsurance. Medically necessary travel, other than transportation by a licensed ambulance
service, to the nearest facility qualified to treat the patient's medical condition is covered when
approved in advance by PacificSource.
• This plan covers biofeedback to treat migraine headaches or urinary incontinence when provided
by an otherwise eligible practitioner.
• This plan covers blood transfusions, including the cost of blood or blood plasma.
• This plan covers removal, repair, or replacement of an internal breast prosthesis due to a
contracture or rupture, but only when the original prosthesis was for a medically necessary
mastectomy. Preauthorization by PacificSource is required, and eligibility for benefits is subject to
the following criteria:
- The contracture or rupture must be clinically evident by a physician's physical examination,
imaging studies, or findings at surgery.
- This plan covers removal, repair, and/or replacement of the prosthesis; a new reconstruction is
not covered.
- Removal, repair, and/or replacement of the prosthesis is not covered when recommended due
to an autoimmune disease, connective tissue disease, arthritis, allergenic syndrome,
psychiatric syndrome, fatigue, or other systemic signs or symptoms.
PacificSource may require a signed loan receipt/subrogation agreement before providing
coverage for this benefit.
• This plan covers breast reconstruction in connection with a medically necessary mastectomy.
Coverage is provided in a manner determined in consultation with the attending physician and
patient for:
- All stages of reconstruction of the breast on which the mastectomy was performed;
- Surgery and reconstruction of the other breast to produce a symmetrical appearance;
- Prostheses; and
Treatment of physical complications of the mastectomy, including lymphedema
Benefits for breast reconstruction are subject to all terms and provisions of the plan, including
deductibles, co-payments and/or co-insurance stated in your Medical Benefit Summary.
• This plan covers cardiac rehabilitation as follows:
- Phase I (inpatient) services are covered under inpatient hospital benefits.
- Phase II (short-term outpatient) services are covered subject to the deductible, co-payment,
and/or co-insurance stated in your Medical Benefit Summary for outpatient hospital
benefits. Benefits are limited to services provided in connection with a cardiac rehabilitation
exercise program that does not exceed 36 sessions and that are considered reasonable
and necessary.
- Phase III (long-term outpatient) services are not covered.
• This plan covers IUD, diaphragm, and cervical cap contraceptive devices along with their
insertion or removal. Contraceptive devices that can be obtained over the counter or without a
prescription, such as condoms are not covered.
• This plan covers corneal transplants. Preauthorization is not required.
• In the following situations, this plan covers one attempt at cosmetic or reconstructive surgery:
When necessary to correct a functional disorder; or
- When necessary because of an accidental injury, or to correct a scar or defect that resulted
from treatment of an accidental injury; or
- When necessary to correct a scar or defect on the head or neck that resulted from a
covered surgery.
Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar,
or defect first occurred. Preauthorization by PacificSource is required for all cosmetic and
SingleSource Self-Insured 41
Exhibit 'A'
reconstructive surgeries covered by this plan. For information on breast reconstruction, see 'breast
prosthesis' and 'breast reconstruction' in this section.
• This plan covers dental and orthodontic services for the treatment of craniofacial anomalies when
medically necessary to restore function. Coverage includes but is not limited to physical disorders
identifiable at birth that affect the bony structures of the face or head, such as cleft palate, cleft lip,
craniosynostosis, craniofacial microsomia and Treacher Collins syndrome. Coverage is limited to
the least costly clinically appropriate treatment. Cosmetic procedures and procedures to improve on
the normal range of functions are not covered. See the exclusions for cosmetic/reconstructive
services, dental examinations and treatment, jaw surgery, and orthognathic surgery under the
'Excluded Services' section
• This plan provides coverage for certain diabetic supplies and training as follows:
- Diabetic supplies other than insulin and syringes (such as lancets, test strips, and glucostix)
are covered subject to the deductible, co-payment, and/or co-insurance stated in your
Medical Benefit Summary for durable medical equipment. You may purchase those
supplies from any retail outlet and send your receipts to PacificSource, along with your
name, group number, and member ID number. PacificSource will process the claim and
mail you a reimbursement check.
- Diabetic insulin and syringes are covered under your prescription drug benefit, if your plan
includes prescription coverage. Lancets and test strips are also available under that
prescription benefit in lieu of those covered supplies under the medical plan.
- This plan covers one diabetes self-management education program at the time of
diagnosis, and up to three hours of education per year if there is a significant change in
your condition or its treatment. To be covered, the training must be provided by an
accredited diabetes education program, or by a physician, registered nurse, nurse
practitioner, certified diabetes educator, or licensed dietitian with expertise in diabetes.
- This plan covers medically necessary telemedical health services provided in connection
with the treatment of diabetes (see Professional Services in this section).
• This plan covers dietary or nutritional counseling provided by a registered dietitian under certain
circumstances. It is covered under the diabetic education benefit, or for management of inborn
errors of metabolism (excluding obesity), or for management of anorexia nervosa or bulimia
nervosa (to a lifetime maximum of five visits).
• This plan covers nonprescription elemental enteral formula ordered by a physician for home use.
Formula is covered when medically necessary to treat severe intestinal malabsorption and the
formula comprises a predominant or essential source of nutrition. Coverage is subject to the
deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable
medical equipment.
• This plan covers routine foot care for patients with diabetes mellitus.
• Hospitalization for dental procedures is covered when the patient has another serious medical
condition that may complicate the dental procedure, such as serious blood disease, unstable
diabetes, or severe cardiovascular disease, or the patient is physically or developmentally disabled
with a dental condition that cannot be safely and effectively treated in a dental office. Coverage
requires preauthorization by PacificSource, and only charges for the facility, anesthesiologist, and
assistant physician are covered. Hospitalization because of the patient's apprehension or
convenience is not covered.
• This plan covers treatment for inborn errors of metabolism involving amino acid, carbohydrate,
and fat metabolism for which widely accepted standards of care exist for diagnosis, treatment, and
monitoring exist, including quantification of metabolites in blood, urine or spinal fluid or enzyme or
DNA confirmation in tissues. Coverage includes expenses for diagnosing, monitoring and
controlling the disorders by nutritional and medical assessment, including but not limited to clinical
visits, biochemical analysis and medical foods used in the treatment of such disorders. Nutritional
supplies are covered subject to the deductible, co-payment, and/or co-insurance stated in your
Medical Benefit Summary for durable medical equipment.
• Injectable drugs and biologicals administered by a physician are covered when medically
necessary for diagnosis or treatment of illness or injury. This benefit does not include
immunizations (see Preventive Care Services in this section) or drugs or biologicals that can be
self-administered or are dispensed to a patient.
SingleSource Self-Insured 42
Exhibit'A'
• This plan covers maxillofacial prosthetic services when prescribed by a physician as necessary
to restore and manage head and facial structures. Coverage is provided only when head and facial
structures cannot be replaced with living tissue, and are defective because of disease, trauma, or
birth and developmental deformities. To be covered, treatment must be necessary to control or
eliminate pain or infection or to restore functions such as speech, swallowing, or chewing.
Coverage is limited to the least costly clinically appropriate treatment, as determined by the
physician. Cosmetic procedures and procedures to improve on the normal range of functions are
not covered. Dentures, prosthetic devices for treatment of TMJ conditions, and artificial larynx are
also not covered.
• Pediatric dental care is not covered.
• The routine costs of care associated with approved clinical trials are covered. Benefits are
only provided for routine costs of care associated with approved clinical trials. Expenses for
services or supplies that are not considered routine costs of care are not covered. For more
information, see 'routine costs of care' in the Definitions section of this Summary Plan Description.
A'qualified individual' is someone who is eligible to participate in a qualifying clinical trial. If a
participating provider is participating in an approved clinical trial, the qualified individual may be
required to participate in the trial through that participating provider if the provider will accept the
individual as a participant in the trial.
• Sleep studies are covered when ordered by a pulmonologist, neurologist, otolaryngologist, or
certified sleep medicine specialist, and when performed at a certified sleep laboratory.
• This plan covers medically necessary therapy and services for the treatment of traumatic brain
injury.
• This plan covers tubal ligation and vasectomy procedures with no waiting period.
BENEFIT LIMITATIONS AND EXCLUSIONS
Least Costly Setting for Services
Covered services must be performed in the least costly setting where they can be provided safely. If a
procedure can be done safely in an outpatient setting but is performed in a hospital inpatient setting,
this plan will only pay what it would have paid for the procedure on an outpatient basis. If services are
performed in an inappropriate setting, your benefits can be reduced by up to 30 percent or $2,500,
whichever is less.
EXCLUDED SERVICES
A Note About Optional Benefits
If your Plan Sponsor provides coverage for optional benefits such as prescription drugs, vision services,
chiropractic care, or alternative care, you'll find those Member Benefit Summaries in this Summary Plan
Description. If your Plan Sponsor provides optional benefits for an exclusion listed below, then the
exclusion does not apply to the extent that coverage exists under the optional benefit. For example, if
your Plan Sponsor provides optional chiropractic coverage, then the exclusion for chiropractic care
listed below under 'Types of Treatment' does not apply to you.
Types of Treatment - This plan does not cover the following:
• Acupuncture
• Chelation therapy including associated infusions of vitamins and/or minerals, except as medically
necessary for the treatment of selected medical; conditions and medically significant heavy metal
toxicities
• Day care or custodial care - Care and related services designed essentially to assist a person in
maintaining activities of daily living, e.g. services to assist with walking, getting in/out of bed,
bathing, dressing, feeding, preparation of meals, homemaker services, special diets, rest cures,
day care, and diapers. Custodial care is only covered in conjunction with respite care allowed under
this plan's hospice benefit. For related provisions, see 'Hospital and Skilled Nursing Facility
Services' and 'Home Health and Hospice Services' in the Covered Expenses section of this
Summary Plan Description.
SingleSource Self-Insured 43
Exhibit 'A'
• Dental examinations and treatment, which means any services or supplies to prevent, diagnose, or
treat diseases of the teeth and supporting tissues or structures, except as specified in Covered
Expenses - Preventive Care Services except as specifically provided with a separate PacificSource
Dental Plan (See the Dental Benefit Plan section of this Summary Plan Description).
• Eye exercises, therapy, and procedures - Orthoptics, vision therapy, and procedures intended to
correct refractive errors
• Fitness or exercise programs and health or fitness club memberships
• Foot care (routine) - Services and supplies for corns and calluses of the feet, conditions of the
toenails other than infection, hypertrophy or hyperplasia of the skin of the feet, and other routine
foot care, except in the case of patients being treated for diabetes mellitus
• Genetic (DNA) testing, except for tests identified as medically necessary for the diagnosis and
standard treatment of specific diseases
• Homeopathic treatment
• Infertility - Services and supplies, surgery, treatment, or prescriptions to prevent, or cure infertility
or to induce fertility (including Gamete and/or Zygote Interfallopian Transfer; i.e. GIFT or ZIFT),
except for medically necessary medication to preserve fertility during treatment with cytotoxic
chemotherapy. For related provisions, see the exclusion for 'family planning' in this section. For
purposes of this plan, infertility is defined as:
o Male: Low sperm counts or the inability to fertilize an egg
o Female: The inability to conceive or carry a pregnancy to 12 weeks
• Instructional or educational programs, except diabetes self-management programs
• Jaw- Services or supplies for developmental or degenerative abnormalities of the jaw,
malocclusion, dental implants, or improving placement of dentures.
• Massage, massage therapy, or neuromuscular re-education, even as part of a physical therapy
program
• Motion analysis, including videotaping and 3-D kinematics, dynamic surface and fine wire
electromyography, and physician review
• Myeloablative high dose chemotherapy, except when the related transplant is specifically covered
under the transplantation provisions of this plan. For related provisions, see 'Transplant Services' in
the Covered Expenses section of this Summary Plan Description.
• Naturopathic treatment
• Obesity or weight control - Surgery or other related services or supplies provided for weight control
or obesity (including all categories of obesity) except as listed under 'Preventive Care Services',
whether or not there are other medical conditions related to or caused by obesity. This also
includes services or supplies used for weight loss, such as food supplementation programs and
behavior modification programs, regardless of the medical conditions that may be caused or
exacerbated by excess weight, and self-help or training programs for weight control. Obesity
screening and counseling are covered for children and adults; see the 'dietary or nutritional
counseling' section under'Other Covered Services'.
• Oral/facial motor therapy for strengthening and coordination of speech-producing musculature and
structures
• Osteopathic manipulation, except for treatment of disorders of the musculoskeletal system
• Physical or eye examinations required for administrative purposes such as participation in athletics,
admission to school, or by a Plan Sponsor
• Private nursing service
• Programs that teach a person to use medical equipment, care for family members, or self
administer drugs or nutrition (except for diabetic education benefit)
• Rehabilitation - Functional capacity evaluations, work hardening programs, vocational
rehabilitation, community reintegration services, and driving evaluations and training programs
• Routine services and supplies - Services, supplies, and equipment not involved in diagnosis or
treatment but provided primarily for the comfort, convenience, cosmetic purpose, environmental
SingleSource Self-Insured 44
Exhibit'A'
control, or education of a patient or for the processing of records or claims. These include but are
not limited to:
o Missed appointments, completion of claim forms, or reports requested by PacificSource in
order to process claims
o Appliances, such as air conditioners, humidifiers, air filters, whirlpools, hot tubs, heat
lamps, or tanning lights
o Private nursing services or personal items such as telephones, televisions, and guest
meals in a hospital or skilled nursing facility
o Maintenance supplies and equipment not unique to medical care
• Screening tests - Services and supplies, including imaging and screening exams performed for the
sole purpose of screening and not associated with specific diagnoses and/or signs and symptoms
of disease or of abnormalities on prior testing (including but not limited to total body CT imaging, CT
colonography and bone density testing).This does not include preventive care screenings listed
under 'Preventive Care Services' in the Covered Expenses section of this Summary Plan
Description.
• Self-help or training programs
• Sexual disorders - Services or supplies for the treatment of sexual dysfunction or inadequacy
unless medically necessary to treat a mental health issue and diagnosis. For related provisions,
see the exclusions for'family planning', 'infertility', and 'mental illness' in this section.
• Snoring - Services or supplies for the diagnosis or treatment of snoring or upper airway resistance
disorders, including somnoplasty
• Speech therapy - Oral/facial motor therapy for strengthening and coordination of speech-producing
muscles and structures, except as medically necessary in the restoration or improvement of speech
following a traumatic brain injury or for a child 17 years of age or younger diagnosed with a
pervasive developmental disorder.
• Temporomandibular joint (TMJ)-related services, or treatment for associated myofascial pain,
including physical or oromyofacial therapy
Surgeries and Procedures - This plan does not cover the following:
• Abdominoplasty for any indication
• Artificial insemination, in vitro fertilization, or GIFT procedures
• Cosmetic/reconstructive services and supplies - Except as specified in the Covered Expenses -
Other Covered Services, Supplies, and Treatments section of this Summary Plan Description,
services and supplies, including drugs, rendered primarily for cosmetic/reconstructive purposes and
any complications as a result of non-covered cosmetic/reconstructive surgery.
Cosmetictreconstructive services and supplies are those performed primarily to improve the body's
appearance and not primarily to restore impaired function of the body, regardless of whether the
area to be treated is normal or abnormal.
• Electronic Beam Tomography (EBT)
• Eye refraction procedures, orthoptics, vision therapy, or other services to correct refractive error
except as indicated in the Covered Services section of this Summary Plan Description
• Jaw surgery - Treatment for abnormalities of the jaw, malocclusion, or improving the placement of
dentures and dental implants
• Orthognathic surgery - Services and supplies to augment or reduce the upper or lower jaw, except
as specified under 'Professional Services' in the Covered Expenses section of this Summary Plan
Description.
• Panniculectomy for any indication
• Sex reassignment - Procedures, services or supplies related to a sex reassignment unless
medically necessary. For related provisions, see exclusions for'mental illness' in this section.
o Excluded procedures include, but are not limited to: staged gender reassignment surgery,
including breast augmentation; penile implantation; liposuction, thyroid chondroplasty,
SingleSource Self-Insured 45
Exhibit 'A'
laryngoplasty, or shortening of the vocal cords, and/or hair removal specifically to assist the
appearance of other characteristics of gender reassignment.
• Surgery to reverse voluntary sterilization
• Transplants - Any services, treatments, or supplies for the transplantation of bone marrow or
peripheral blood stem cells or any human body organ or tissue, except as expressly provided under
the provisions of this plan for covered transplantation expenses. For related provisions see
'Transplant Services' in the Covered Expenses section of.this Summary Plan Description.
Mental Health Services - This plan does not cover the following services, whether provided by a
mental health or chemical dependency specialist or by any other provider:
Treatment for the following diagnosis:
• Diagnostic codes V 15.81 through V71.09 (DSM-IV-TR, Forth Edition) except V61.20, V61.21, and
V62.82 when used with children five years of age or younger
• Food dependencies
• Gender Identity Disorders in Adults (GID)
• Learning disorders
• Mental illness does not include - Treatment of intellectual disabilities; learning disorders;
paraphilias; and relationship problems (e.g. parent-child, partner, sibling, or other relationship
issues), except the treatment of children five years of age or younger for parent-child relational
problems, physical abuse of a child, sexual abuse of a child, neglect of a child, or bereavement.
This plan does not cover educational or correctional services or sheltered living provided by a
school or halfway house, except outpatient services received while temporarily living in a shelter;
psychoanalysis or psychotherapy received as part of an educational or training program, regardless
of diagnosis or symptoms that may be present; a court-ordered sex offender treatment program; a
court-ordered screening interview or drug or alcohol treatment program; or nicotine related
disorders.
The following treatment types are also excluded, regardless of diagnosis: marital/partner
counseling; support groups; sensory integration training; biofeedback except to treat migraine
headaches or urinary incontinence; hypnotherapy; academic skills training; narcosynthesis;
aversion therapy; and social skill training. Recreation therapy is only covered as part of an inpatient
or residential admission.
The following are also excluded: court-mandated diversion and/or chemical dependency education
classes; court-mandated psychological evaluations for child custody determinations; voluntary
mutual support groups such as Alcoholics Anonymous; adolescent wilderness treatment programs;
mental examinations for the purpose of adjudication of legal rights; psychological testing and
evaluations not provided as an adjunct to treatment or diagnosis of a stress management,
parenting skills, or family education, assertiveness training; image therapy; sensory movement
group therapy; marathon group therapy; sensitivity training; and psychological evaluation for sexual
dysfunction or inadequacy.
• Mental retardation for individuals 18 years of age or older
• Nicotine related disorders
• Paraphilias
Treatment programs, training, or therapy as follows:
• Academic skills training
• Aversion therapy
• Biofeedback (other than as specifically noted under the Covered Expenses - Other covered
Services, Supplies, and Treatment section)
• Court-ordered sex offender treatment programs
• Court-ordered screening interviews or drug or alcohol treatment programs
• Educational or correctional services or sheltered living provided by a school or halfway house
• Equine/animal therapy
SingleSource Self-Insured 46
Exhibit'A'
• Hypnotherapy
• Narcosynthesis
• Psychoanalysis or psychotherapy received as part of an educational or training program,
regardless of diagnosis or symptoms that may be present
• Marital/partner counseling
• Recreation therapy outside a inpatient or residential treatment setting
• Sensory integration training
• Social skill training
• Support groups
Drugs and Medications - This plan does not cover the following:
Drugs and biologicals that can be self administered (including injectibles), other than those
provided in a hospital emergency room, or other institutional setting, or as outpatient chemotherapy
and dialysis, which are covered
• Drugs or medications not prescribed for inborn errors of metabolism, diabetic insulin, or autism
spectrum disorder that can be self-administered (including prescription drugs, injectable drugs, and
biologicals), unless given during a visit for outpatient chemotherapy or dialysis or during a medically
necessary hospital, emergency room or other institutional stay.
• Growth hormone injections or treatments, except to treat documented growth hormone deficiencies
• Immunizations when recommended for or in anticipation of exposure through travel or work
• Over-the-counter medications or non-prescription drugs
Equipment and Devices - This plan does not cover the following:
• Computer or electronic equipment for monitoring asthmatic, diabetic, or similar medical conditions
or related data
• Equipment commonly used for nonmedical purposes - This plan does not cover the following:
o Equipment commonly used for nonmedical purposes, or marketed to the general public, or
intended to alter the physical environment. This includes appliances like adjustable power
beds sold as furniture, air conditioners, air purifiers, room humidifiers, heating and cooling
pads, home blood pressure monitoring equipment, light boxes, conveyances other than
conventional wheelchairs, whirlpool baths, spas, saunas, heat lamps, tanning lights, and
pillows. It also includes orthopedic shoes and shoe modifications. Mattresses and mattress
pads are only covered when medically necessary to heal pressure sores.
o Modifications to vehicles or structures to prevent, treat, or accommodate a medical
condition
o Replacement costs for worn or damaged durable medical equipment that would otherwise
be replaceable without charge under warranty or other agreement
o Personal items such as telephones, televisions, and guest meals during a stay at a hospital
or other inpatient facility
• Equipment used primarily in athletic or recreational activities. This includes exercise equipment for
stretching, conditioning, strengthening, or relief of musculoskeletal problems
• Modifications to vehicles or structures to prevent, treat, or accommodate a medical condition
• Personal items such as telephones, televisions, and guest meals during a stay at a hospital or other
inpatient facility
• Replacement costs for worn or damaged durable medical equipment that would otherwise be
replaceable without charges under warranty or other agreement
Experimental or Investigational Treatment
Your Plan Sponsor's plan does not cover experimental or investigational treatment. By that,
PacificSource means services, supplies, protocols, procedures, devices, chemotherapy, drugs or
SingleSource Self-Insured 47
Exhibit 'A'
medicines or the use thereof that are experimental or investigational for the diagnosis and treatment of
the patient. It includes treatment that, when and for the purpose rendered:
• Has not yet received full U.S. government agency approval (e.g. FDA) for other than experimental,
investigational, or clinical testing;
• Is not of generally accepted medical practice in Oregon or as determined by PacificSource in
consultation with medical advisors, medical associations, and/or technology resources,
• Is not approved for reimbursement by the Centers for Medicare and Medicaid Services;
• Is furnished in connection with medical or other research; or
• Is considered by any governmental agency or subdivision to be experimental or investigational, not
reasonable and necessary, or any similar finding.
An experimental or investigational service is not made eligible for benefits by the fact that other
treatment is considered by your healthcare provider to be ineffective or not as effective as the service or
that the service is prescribed as the most likely to prolong life.
When making benefit determinations about whether treatments are investigational or experimental,
PacificSource relies on the above resources as well as:
• Expert opinions of specialists and other medical authorities;
• Published articles in peer-reviewed medical literature,
• External agencies whose role is the evaluation of new technologies and drugs; and
• External review by an independent review organization.
The following will be considered in making the determination whether the service is in an experimental
and/or investigational status:
• Whether there is sufficient evidence to permit conclusions concerning the effect of the services on
health outcomes;
• Whether the scientific evidence demonstrates that the services improve health outcomes as much
or more than established alternatives,
• Whether the scientific evidence demonstrates that the services' beneficial effects outweigh any
harmful effects; and
• Whether any improved health outcomes from the services are attainable outside an investigational
setting.
If you or your provider have any concerns about whether a course of treatment will be covered,
PacificSource encourages you to contact PacificSource's Customer Service Department. PacificSource
will arrange for medical review of your case against PacificSource's criteria, and notify you of whether
the proposed treatment will be covered.
Otherltems - This plan does not cover the following:
• Treatment not medically necessary - Services or supplies that are not medically necessary for the
diagnosis or treatment of an illness, injury, or disease. For related provisions, see 'medically
necessary' in the Definitions section and 'Understanding Medical Necessity' in the Covered
Expenses section of this Summary Plan Description.
• Treatment prior to enrollment - Services or supplies a member received prior to enrolling in
coverage provided by this plan; charges for inpatient stays that begin before you were covered by
this plan; services or supplies received before this plan's coverage began; admission prior to
coverage; services and supplies for an admission to a hospital, skilled nursing facility or specialized
facility that began before the patient's coverage under this plan
• Treatment after insurance ends - Services or supplies received after enrollment in this policy ends.
(The only exception is if this policy is replaced by another group health policy while you are
hospitalized. The plan will continue paying covered hospital expenses until you are released or your
benefits are exhausted, whichever occurs first.)
• Care and related services designed essentially to assist a person in maintaining activities of daily
living, e.g. services to assist with walking, getting in/out of bed, bathing, dressing, feeding, and
SingleSource Self-Insured 48
Exhibit'A'
preparation of meals, homemaker services, special diets, rest crew, day care, and diapers.
Custodial care is only covered in conjunction with respite care allowed under this policy's hospice
benefit (see Covered Expenses - Hospital, Skilled Nursing Facility, Home Health, and Hospice
Services).
• Services or supplies available to you from another source, including those available through a
government agency
• Services or supplies for which no charge is made, for which the member is not legally required to
pay, or for which a provider or facility is not licensed to provide even though the service or supply
may otherwise be eligible. This exclusion includes services provided by the member, or by an
immediate family member.
• Services or supplies for which you are not willing to release the medical or eligibility information
PacificSource needs to determine the benefits paid under this plan
• Charges that are the responsibility of a third party who may have caused the illness, injury, or
disease or other insurers covering the incident (such as workers' compensation insurers,
automobile insurers, and general liability insurers)
• Charges over the usual, customary, and reasonable fee (UCR) - Any amount in excess of the UCR
for a given service or supply, except alternative rare.
• Treatment of any illness, injury, or disease resulting from an illegal occupation or attempted felony,
or treatment received while in the custody of any law enforcement authority
• Treatment of any condition caused by a war, armed invasion, or act of aggression, or while serving
in the armed forces
• Treatment of any work-related illness or injury, unless you are the owner, partner, or principal of the
Plan Sponsor, injured in the course of employment of the Plan Sponsor, and are otherwise exempt
from, and not covered by, state or federal workers' compensation insurance. This includes illness or
injury caused by any for-profit activity, whether through employment or self-employment.
• Treatment while incarcerated - Services or supplies a member receives while in the custody of any
state or federal law enforcement authorities or while in jail or prison
• Charges for phone consultations, missed appointments, get acquainted visits, completion of claim
forms, or reports PacificSource needs to process claims
• Any amounts in excess of the allowable fee for a given service or supply Training or self-help
programs - General fitness exercise programs, and programs that teach a person how to use
durable medical equipment or care for a family member. Also excluded are health or fitness club
services or memberships and instruction programs, including but not limited to those to learn to
self-administer drugs or nutrition, except as specifically provided for in this plan.
• Services of providers who are not eligible for reimbursement under this plan. An individual
organization, facility, or program is not eligible for reimbursement for services or supplies,
regardless of whether this plan includes benefits for such services or supplies, unless the
individual, organization, facility, or program is licensed by the state in which services are provided
as an independent practitioner, hospital, ambulatory surgical center, skilled nursing facility, durable
medical equipment supplier, or mental and/or chemical healthcare facility. And to the extent
PacificSource maintains credentialing requirements the practitioner or facility must satisfy those
requirements in order to be considered an eligible provider.
• Scheduled and/or non-emergent medical care outside of the United States.
• Services otherwise available - These include but are not limited to:
o Services or supplies for which payment could be obtained in whole or in part if the member
applied for payment under any city, county, state (except Medicaid), or federal law; and
o Services or supplies the member could have received in a hospital or program operated by
a federal government agency or authority, except otherwise covered expenses for services
or supplies furnished to a member by the Veterans' Administration of the United States that
are not military service-related.
This exclusion does not apply to covered services provided through Medicaid or by any hospital
owned or operated by the State of Oregon or any state-approved community mental health and
developmental disability program.
SingleSource Self-Insured 49
Exhibit'A'
• Benefits not stated - Services and supplies not specifically described as benefits under the group
health policy and/or any endorsement attached hereto
EXCLUSION PERIODS
Exclusion Period for Transplant BeneEts
Except for corneal transplants, organ and tissue transplants are not covered until you have been
enrolled in this plan for 24 months or since birth. If you were covered under another health insurance
plan before enrolling in this plan, you can receive credit for your prior coverage. See the Credit for Prior
Coverage section, below.
CREDIT FOR PRIOR COVERAGE
You can receive credit toward this plan's exclusion periods if you had qualifying healthcare coverage
before enrolling in this plan. To qualify for this credit, there may not have been more than a 63-day
gap between your last day of coverage under the previous health plan and your first day of coverage
(or the first day of your Plan Sponsor's probationary waiting period) under this plan.
Your prior coverage must have been a group health plan, COBRA or state continuation coverage,
individual health policy (including student plans), Medicare, Medicaid, TRICARE, State Children's
Health Insurance Program, and coverage through high risk pools and the Peace Corps. If you were
covered as a dependent under a plan that meets these qualifications, you will qualify for credit. Many
people elect the COBRA or state continuation coverage available under a prior plan to make sure they
won't have more than a 63-day gap in coverage.
It is your responsibility to show you had creditable coverage. If you qualify for credit, PacificSource
will count every day of coverage under your prior plan toward this plan's exclusion periods for pre-
existing conditions, other specified conditions, and transplants (explained above).
Evidence of Prior Creditable Coverage
You can show evidence of creditable coverage by sending PacificSource a Certificate of Creditable
Coverage from your previous health plan. All health plans, insurance companies, and HMOs are
required by law to provide these certificates on request. Most insurers issue these certificates
automatically whenever someone's coverage ends. The certificate shows how long you were covered
under your previous plan and when your coverage ended.
If you do not have a certificate of prior coverage, contact your previous insurance company or Plan
Sponsor (such as your former employer, if you had a group health plan). You have the right to request a
certificate from any prior plan, insurer, HMO, or other entity through which you had creditable coverage.
If you are unable to obtain a certificate, contact PacificSource's Membership Services Department for
assistance.
HEALTH CARE MANAGEMENT AND PREAUTHORIZATION
What is Health Care Management
Your Plan Sponsor desires to provide you and your family with a heath care benefit plan that financially
protects you from significant health care expenses and assures you quality care. While part of
increasing health care costs results from new technology and important medical advances, another
significant cause is the way health care services are used.
Some studies indicate that a high percentage of the cost for health care services may be unnecessary.
For example, hospital stays may be longer than necessary. Some hospitalizations may be entirely
avoidable, such as when surgery could be performed at an outpatient facility with equal quality and
safety. Also, surgery is sometimes performed when other treatment could be more effective. All of these
instances increase costs for you and the plan.
Your Plan Sponsor has contracted with PacificSource to assist you in determining whether or not
proposed services are appropriate for reimbursement under this plan. The program is not intended to
diagnose or treat medical conditions, dictate a treatment plan, guarantee benefits, or validate eligibility.
SingleSource Self-Insured 50
Exhibit'A'
The medical professionals who conduct the program focus their review on the appropriateness for
reimbursement of hospital stays and proposed surgical procedures.
Required Admission Review - You are required to call PacificSource's toll-free number, (888) 977-
9299, prior to any elective inpatient stay or any scheduled surgical procedure. In most cases, your
medical provider will make the call for you. You must also call within 48 hours of any emergency
admission. When you or your provider call, it will be necessary to provide the program with your name,
the patient's name, the name of the physician or practitioner and hospital, the reason for the
hospitalization and any other information needed to complete the review. In some cases, you may be
asked for more information or a second opinion may be required to complete the review.
Preauthorization - Preauthorization is necessary to determine if certain services and supplies are
covered under this plan and if you meet the plan's eligibility requirements. PacificSource reviews new
technologies and standards of medical practice on an ongoing basis and therefore the list of
preauthorization requirements is subject to changes and updates. The current list of procedures and
services that require preauthorization under the plan can be found the PacificSource' website:
PacificSource.com.
The list of services that require preauthorization is not intended to suggest that all the items
included are necessarily covered by the benefits of this plan.
A request for preauthorization must be made to PacificSource as soon as the patient knows that he or
she will be receiving services for which preauthorization is required. Your medical provider can request
preauthorization from PacificSource by phone - (888) 977-9299, fax - (541) 684-5264, or mail:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extensi6n 1009
cs@pacificsource.com
If your provider will not request preauthorization for you, you may contact PacificSource yourself. In
some cases, you may be asked for more information or be required to obtain a second opinion before a
benefit determination can be made.
If you are preauthorized for one facility, but are then transferred to another facility you will need to
obtain preauthorization for the new facility before transferring, except in the case of emergencies in
which case notification must be made as soon as possible after transferring facilities.
If your provider's preauthorization request is denied as not medically necessary or as experimental,
your provider may appeal the adverse benefit determination. You retain the right to appeal the adverse
benefit determination independent from your provider.
Note: A preauthorization determination is valid for 90 days. However, if your coverage under the plan
ends before the services are rendered or supplies received, the preauthorization determination will
become invalid.
Case Management
The primary objective of large case management is to identify and coordinate cost-effective medical
care alternatives and to help manage the care of patients who have special or extended care illnesses
or injuries. Large case management also monitors the care of the patient, offers emotional support to
the family, and coordinates communications among health care providers, patients and others.
Benefits may be modified by the Plan Sponsor to permit a method of treatment not expressly provided
for, but not prohibited by law, rules or public policy, if the Plan Sponsor determines that such
modification is medically necessary and is more cost-effective than continuing a benefit to which you or
your eligible dependents may otherwise be entitled. The Plan Sponsor also reserves the right to limit
payment for services to those amounts which would have been charged had the service been provided
in the most cost-effective setting in which the service could safely have been provided.
Examples of illnesses or injuries that may be appropriate for large case management include, but are not
limited to:
SingleSource Self-Insured 51
Exhibit'A'
• Terminal illnesses (Cancer, AIDS, Multiple Sclerosis, Renal Failure, Obstructive Pulmonary
Disease, Cardiac conditions, etc.)
• Accident victims requiring long-term rehabilitative care
• Newborns with high-risk complications or multiple birth defects
• Diagnoses involving long-term IV therapy
• Illnesses not responding to medical care
• Child and adolescent mental/nervous disorders
• Organ transplants
individoai Benerits Management
Individual benefits management addresses, as an alternative to providing covered services,
PacificSource's consideration of economically justified alternative benefits. The decision to allow -
alternative benefits will be made by on a case-by-case basis. The determination to cover and pay for
alternative benefits for an individual shall not be deemed to waive, alter or affect the Plan Sponsor's or
PacificSource's right to reject any other or subsequent request or recommendation. The Plan Sponsor
may provide alternative benefits if PacificSource and the individual's attending provider concur in the
request for and in the advisability of alternative benefits in lieu of specified covered services, and, in
addition, PacificSource concludes that substantial future expenditures for covered services for the
individual could be significantly diminished by providing such alternative benefits under the individual
benefit management program (See Case Management above).
HOW TO USE YOUR DENTAL PLAN
When you need dental care, you may visit any dentist. Most dental offices will bill PacificSource directly.
If your dentist has any questions regarding billing procedures, he or she can call PacificSource at (541)
225-1981, or (866) 373-7053 from outside the Eugene-Springfield area.
When you first visit your dentist after becoming covered under this plan, let the office staff know you
have dental benefits through PacificSource. You will need to show your PacificSource ID card, which
contains your group number and benefit information. Your dentist may submit claims and treatment
programs on a standard American Dental Association form.
For extensive dental work, PacificSource recommends that your dentist submit a pre-treatment
estimate to PacificSource. PacificSource then determines how much your plan will pay toward the
proposed treatment and review the estimate with your dentist prior to treatment. If your covered family
members require extensive dental work, be sure your member ID number and group number are
included on their pre-treatment form for identification purposes.
DENTAL PLAN BENEFITS
When this plan pays for dental services, it actually pays the stated percentage of charges based on
reasonable and customary charges. A charge is reasonable and customary when it falls within a
general range of charges being made by most dental providers in your service area for similar
treatment of similar dental conditions. If the charge for a treatment or service is more than the
reasonable and customary charge in your service area, you may be required to pay the difference. The
reasonable and customary charge for dental expense is the 'covered charge' referred to in this booklet.
If you or your covered family member selects a more expensive treatment than is customarily provided,
this plan will pay the applicable percentage of the lesser fee. You will be responsible for the balance of
the provider's charges.
With the Advantage Network, participating dentists agree to write off any charges over and above the
negotiated, contracted fees for most services. When you use a participating dentist in the Advantage
Network, you will not be responsible for any excess charges and will pay only your plan's deductible
and/or co-insurance amount. If you choose not to use a participating Advantage Network dentist, or
don't have access to them, reimbursement will continue to be based on usual, customary, and
reasonable (UCR) charges. If that non-participating dentist's fees exceed the UCR charges, the excess
charges are also your responsibility
SingleSource Self-Insured 52
Exhibit'A'
COVERED DENTAL SERVICES
This dental plan covers the following services when performed by an eligible' provider and when
determined to be necessary by the standards of generally accepted dental practice for the prevention or
treatment of oral disease or for accidental injury, including masticatory function. Covered services may
also be provided by a dental hygienist or denturist to the extent that he or she is operating within the
scope of his or her license as required under law in the State of Oregon.
Covered dental services are organized into three classes, starting with preventive care and advancing
into specialized dental procedures.
Class I Services - Diagnostic and Preventive Treatment
• Examinations (routine or other diagnostic exams) are covered. Separate charges for review of a
proposed treatment plan or for diagnostic aids such as study models and certain lab tests are not
covered.
• Full mouth x-rays and/or panorex are covered up to one complete mouth series and/or panorex
in any three-year period and limited to four bite-wing films in a six-month period. When an
accumulative charge for additional periapical x-rays in a one-year period matches that of a
complete mouth series, no further benefits for periapical x-rays or panorex are available for the
remainder of the year.
• Dental cleanings (prophylaxis and periodontal maintenance) are covered to a combined total
of three procedures per person per benefit year. The limitation for dental cleaning applies to any
combination of prophylaxis and/or periodontal maintenance in the benefit year. A separate charge
for periodontal charting is not a covered benefit. Periodontal maintenance is not covered when
performed within three months of periodontal scaling and root planing and/or curettage.
• Topical applications of fluoride are covered to two applications per benefit year through age 22.
• Fluoride varnish applications are covered to 12 applications per benefit year for children age 12
and under if the child is deemed at risk for dental infection.
• The application of sealants is covered to one application in a five-year period to permanent
molars and bicuspids and only for individuals through age 17.
• Vizilite is a covered up to two screenings per benefit year.
• Benefits for athletic mouth guards are limited to one per lifetime through age 17 if the member is
still in secondary school.
• Benefits for brush biopsies used to aid in the diagnosis of oral cancer are covered.
Class II Restorative Services - Basic and Restorative Treatment
• Composite, resin, or similar restoration in a posterior (back) tooth is covered to the amount that
would be paid for a corresponding amalgam restoration. A separate charge for anesthesia when
used during restorative procedures is not a covered benefit. Only one filling is allowed per tooth
surface. The Plan Sponsor will pay for a filling on a tooth surface only once per benefit year. Three
or more surface fillings are limited to one per surface per benefit year.
• Simple and surgical extractions of teeth and other minor oral surgery procedures are covered.
General anesthesia used in conjunction with these extractions administered by a dentist in a dental
office is also covered. A separate charge for alveolectomy performed in conjunction with removal of
teeth is not a covered benefit.
• Periodontal scaling and root planing and/or curettage is covered but limited to only one
procedure per quadrant in any 24-month period. For the purpose of this limitation, eight or fewer
teeth existing in one arch will be considered one quadrant.
• Benefits for full mouth debridement are limited to once every 24 months. This procedure is only
covered if the teeth have not received a prophylaxis in the prior 24 months and if an evaluation
cannot be performed due to the obstruction by plaque and calculus on the teeth. This procedure is
not covered if performed on the same date as the prophylaxis.
Class II Complicated Services - Complicated Treatment
Complicated oral surgical procedures such as removal of impacted teeth are covered when
SingleSource Self-Insured 53
Exhibit'A'
preauthorized by PacificSource. Benefits for complicated oral surgical procedures include general
anesthesia administered by a dentist in a dental office. A separate charge for alveolectomy
performed in conjunction with removal of teeth is not a covered benefit.
• Pulp capping is covered only when there is an exposure to the pulp. These are direct pulp caps.
Indirect pulp caps are not covered.
• Pulpotomy is covered only for deciduous teeth.
• Root canal therapy is covered on the same tooth only for one charge in a three-year period.
• Periodontal surgery is covered when the procedure is preauthorized by PacificSource and
accompanied by a periodontal diagnosis and history of conservative (non-surgical) periodontal
treatment.
• Tooth desensitization is covered as a separate procedure from other dental treatment.
• Space maintainers are a covered benefit for individuals through the age of 13.
Class iii Services - Major Treatment
• Crowns and other cast or laboratory-processed restorations are covered but limited to the
restoration of any one tooth in a five-year period. If a tooth can be restored with a material such as
amalgam or composite resin, covered charges are limited to the cost of amalgam or non-laboratory
composite resin restoration even if another type of restoration is selected by the patient and/or
dentist.
• Replacement of an existing prosthetic device is covered only when the device being replaced is
unserviceable, cannot be made serviceable, and has been in place for at least five years.
• Cast partial denture, full, immediate, or overdenture are covered only to the cost of a standard
full or cast partial denture. A separate charge for denture adjustments and relines performed within
six months of the initial placement is not a covered benefit. Benefits for subsequent relines are
provided only once in a 12-month period. Cast restorations for partial denture abutment teeth or for
splinting purposes are not covered unless the tooth in and of itself requires a cast restoration.
• Fixed bridges or removable cast partials are covered. Benefits for temporary full or partial
dentures must be preauthorized. Benefits for the initial placement of full or partial dentures or fixed
bridges (including acid-etch metal bridges) are provided only if the denture or bridgework includes
replacement of a natural tooth which is extracted or lost while the member's coverage is in effect.
However, this limitation does not apply after the member has been covered under the policyholder's
group dental plan for a period of at least 36 consecutive months.
• Benefits for the surgical placement and removal of implants are limited to once per lifetime per
tooth space for each service. Services must be preauthorized by PacificSource to be covered.
Benefits include final crown and implant abutment over a single implant and final implant-supported
bridge abutment and implant abutment or pontic. An alternative benefit per arch of a conventional
full or partial denture for the final implant-supported full or partial denture prosthetic device is
available.
• Bruxism splint and nightguard (appliances to reduce or prevent pain or damage from grinding of
teeth) are covered.
EXCLUDED DENTAL SERVICES
This plan does not provide benefits in any of the following circumstances or for any of the following
conditions:
• Aesthetic dental procedures - Services and supplies provided in connection with dental
procedures that are primarily aesthetic, including bleaching of teeth and labial veneers.
• Antimicrobial agents - Localized delivery of antimicrobial agents into diseased crevicular tissue
via a controlled release vehicle.
• Benefits not stated - Any services and supplies not specifically described as covered benefits
under this plan
• Biopsies or histopathologic exams - A separate charge for a biopsy of oral tissue or
histopathologic exam.
SingleSource Self-Insured 54
Exhibit'A'
• Bone replacement grafts to prepare sockets for implants after tooth extraction.
• Charges for broken appointments
• Collection of cultures and specimens.
• Connector bar or stress breaker.
• Core build-ups are not covered unless used to restore a tooth that has been treated
endodontically (root canal).
• Cosmetic/reconstructive services and supplies - Procedures, appliances, restorations, or other
services that are primarily for cosmetic purposes. This includes services or supplies rendered
primarily to correct congenital or developmental malformations, including but not limited to, peg
laterals, cleft palate, maxillary and mandibular (upper and lower jaw) malformation, enamel
hypoplasia, and fluorosis (discoloration of teeth). However, the replacement of congenitally missing
teeth is covered.
• Denture replacement made by necessary by loss, theft, or breakage.
• Diagnostic casts - Diagnostic casts (study models), gnathological recordings, occlusal
appliances, occlusal equilibration procedures, or similar procedures.
• Drugs and medications that are prescribed drugs, premedication drugs, analgesics (e.g., nitrous
oxide or non-intravenous sedation), any other euphoric drugs, or any take-home medicine or
supplies distributed by a provider.
• Educational programs - Instructions and/or training in plaque control and oral hygiene.
• Experimental or investigational procedures - Services, supplies, protocols, procedures,
devices, drugs or medicines, or the use thereof that are experimental or investigational for the
diagnosis and treatment of the patient. An experimental or investigational service is not made
eligible for benefits by the fact that other treatment is considered by the member's dental care
provider to be ineffective or not as effective as the service or that the service is prescribed as the
most likely to prolong life.
• Fractures of the mandible - Services and supplies provided in connection with the treatment of
simple or compound fractures of the mandible.
• General anesthesia except when administered by a dentist in connection with oral surgery in
his/her office
• Gingivetomcy, gingivoplasty or crown lengthening in conjunction with crown preparation or
fixed bridge services done on the same date of service.
• Hospital charges or additional fees charged by the dentist for hospital treatment
• Hypnosis
• Infection control - A separate charge for infection control or sterilization
• Intra and extra coronal splinting - Devices and procedures for infra and extra coronal splinting to
stabilize mobile teeth.
• Oral Surgery treating any fractured jaw
• Orthodontic services - Treatment of malalignment of teeth and/orjaws, or any ancillary services
expressly performed because of orthodontic treatment, unless your Dental Benefit Summary shows
orthodontic services as a covered benefit.
• Orthognathic surgery - Surgery to manipulate facial bones, including the jaw, in patients with
facial bone abnormalities performed to restore the proper anatomic and functional relationship to
the facial bones
• Periodontal probing, charting, and re-evaluations
• Photographic images.
• Pin retention in addition to restoration.
• Precision attachments
• Pulpotomies on permanent teeth
SingleSource Self-Insured 55
Exhibit'A'
• Removal of clinically serviceable amalgam restorations to be replaced by other materials free
of mercury, except with proof of allergy to mercury.
• Services covered by the member's medical plan.
• Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or
occlusion, or for stabilizing the teeth.
• Services otherwise available - These include but are not limited to:
- Services or supplies for which payment could be obtained in whole or in part if the member
applied for payment under any city, county, state, or federal law (except Medicaid); and
- Services or supplies the member could have received in a hospital or program operated by a
federal government agency or authority. Covered expenses for services or supplies furnished
to a member by the Veterans' Administration of the United States that are not service-related
are eligible for payment according to the terms of this policy.
- Services or supplies for which payment would be made by Medicare.
• Services or supplies for which no charge is made which you are not legally required to pay or
which a provider or facility is not licensed to provide even though the service or supply may
otherwise be eligible. This includes services provided by you or an immediate family member.
• Sinus lift grafts to prepare sinus site for implants.
• Temporomandibular joint (TMJ) - Any services or supplies for treatment of any disturbance of
the Temporomandibular joint.
• Third party liability, motor vehicle liability, motor vehicle insurance coverage, workers'
compensation - Any services or supplies for illness or injury for which a third party is responsible
or which are payable by such third party or which are payable pursuant to applicable workers'
compensation laws, motor vehicle liability, uninsured motorist, underinsured motorist, and personal
injury protection insurance and any other liability and voluntary medical or dental payment
insurance to the extent of any recovery received from or on behalf of such sources.
• Tooth transplantation - Services and supplies provided in connection with tooth transplantation,
including re-implantation from one site to another and splinting and/or stabilization. This exclusion
does not relate to the re-implantation of a tooth into its original socket after it has been avulsed.
• Treatment after insurance ends - Services or supplies provided after enrollment in this plan
ends. The only exception is for Class III Services ordered and fitted before enrollment ends and
placed within 31 days after enrollment ends.
• Treatment not dentally necessary according to acceptable dental practice or treatment not likely
to have a reasonably favorable prognosis.
• Treatment prior to enrollment - Dental services begun before you or your family member
became eligible for those services under this plan.
• Treatment while incarcerated - Services or supplies received while in the custody of any state or
federal law enforcement authorities or while in jail or prison.
• Unwilling to release information - Charges for services or supplies for which you are unwilling to
release medical or dental information necessary to determine eligibility for payment under this
policy
• War-related conditions - The treatment of any condition caused by or arising out of an act of war,
armed invasion, or aggression, or while in the service of the armed forces.
• Work-related conditions - Services or supplies for treatment of illness or injury arising out of or in
the course of employment or self-employment for wages or profit, whether or not the expense for
the service or supply is paid under workers' compensation.
SingleSource Self-Insured 56
Exhibit'A'
CLAIMS PROCEDURES
How to File/How to Appeal a Claim
These claim procedures describe how benefit claims and appeals are made and decided under this
plan.
Only members or a designated authorized representative may submit claims for benefits (for
themselves and on behalf of their covered dependents), and benefits will only be paid to the member or
the actual provider of services. Under the following claims procedures section, the words 'you' and
'your' will mean a member of the group health plan of the Plan Sponsor. You become a claimant when
you make a request for a plan benefit or benefits in accordance with these claims procedures.
You and your covered dependents have the right to elect group health care benefits as offered by the
Plan Sponsor, and your and their rights will be determined under the plan's provisions and in
conjunction with the claims and appeals procedures outlined later in this section. Claims will also be
considered filed by you if communications and requests for benefits come from an individual that you
have designated as your authorized representative to act on your behalf with respect to a claim. In the
event that you designate an authorized representative to act on your behalf, the plan will send all
notifications, requests for further information, appeal decisions, and all other communications to your
authorized representative and provide you with a copy of all communications, unless you request
otherwise in writing.
An authorized representative may act on behalf of a claimant with respect to benefit claim or appeal
under these procedures. However, no person (including a treating health care professional) will be
recognized as an authorized representative until the plan receives an Designation of Authorized
Representative form signed by the claimant, except that for urgent care claims the plan shall, even in
the absence of a signed Designation of Authorized Representative form, recognize a health care
professional with knowledge of the claimant's medical condition (e.g., the treating physician or
practitioner) as the claimant's authorized representative unless the claimant provides specific written
direction otherwise.
A Designation of Authorized Representative form may be obtained from and completed forms must be
returned to:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espahol (800) 624-6052, extension 1009
cs@pacificsou rce. com
An assignment for purposes of payment (e.g., to a health professional) does not constitute appointment
of an authorized representative under these claims procedures. However, unless you have directed the
plan otherwise, claims submitted on your behalf by a health care professional will be considered a valid
claim if submitted pursuant to the guidelines outlined in these claim procedures.
Any reference in these claims procedures to the claimant is intended to include the authorized
representative of such claimant appointed in compliance with the above procedures.
For the purposes of the claims procedures section, any reference to 'days' will refer to calendar days,
not business days.
Questions about Your Claims
PacificSource is available to listen and help with any concerns or problems you may have with resolving
a claim. Because PacificSource wants you to be completely satisfied with the member services
assistance you receive, a process has been established for addressing your concerns and solving your
problems. If you have a concern regarding a person, a service, the quality of care, or you want to
inquire about what benefits are covered under the plan, please call PacificSource at (888) 977-9299
and explain your concern to one of their Customer Service Representatives. You may also express that
concern in writing. PacificSource will do their best to resolve the matter on your initial contact. If
PacificSource needs more time to review or investigate your concern, they will get back to you as soon
SingleSource Self-Insured 57
Exhibit'A'
as possible, but in any case within 30 days. They will not consider any of these communications to be a
'claim' for benefits. A formal claim for benefits must meet certain other standards which are described in
greater detail in these procedures.
Types of Claims
Pre-Service Claims - The plan subjects the receipt of benefits for some services or supplies to a
preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it
may in some cases be conducted on a post-service basis. Unless a response is needed sooner due to
the urgency of the situation, a pre-service preauthorization review will be completed and notification
made to you and your medical provider as soon as possible, generally within two working days, but no
later than 15 days within receipt of the request.
Urgent Care Claims - If the time period for making a non-urgent care determination could seriously
jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain
that cannot be adequately managed without the care or treatment that is proposed, a preauthorization
review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours
within receipt of the request.
Concurrent Care Review - A concurrent care decision occurs when a previously approved course of
treatment is reconsidered and reduced or denied, or where an extension is requested beyond the
initially approved period of time or number of treatments. Inpatient hospital or rehabilitative facilities,
skilled nursing facilities, intensive outpatient, and residential behavioral health care require concurrent
review for a benefit determination with regard to an appropriate length of stay or duration of service.
Benefit determinations will be made as soon as possible within receipt of all the information necessary
to make such a determination.
Post-Service Claims - A claim determination that involves only the potential payment of
reimbursement of the cost of medical care that has already been provided will be made as soon as
reasonably possible but no later than 30 days from the day after receiving the claim.
How to File a Claim
Most health care providers will file claims on your behalf. Electronically submitted claims are processed
most efficiently. If unable to file electronically, you, your health care provider, or an authorized
representative must file your claim using HCFA-1500 (revision 12/90 and later), UB92, or ADA (revision
12/90 and later) forms, or an itemized statement. These forms are available from your health care
provider or PacificSource.
A claim will be considered filed when it is received by PacificSource at the address listed below:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espahol (800) 624-6052, extension 1009
cs@ pacificsou rce. com
The following information is required in order qualify your request for benefits as a properly submitted
claim:
• Plan member's name, member ID and current address;
• Patient's name, member ID and address if different from the member's;
• Provider's name, tax identification number, address, degree and signature;
• Date(s) of service(s);
• Place of service(s);
Diagnostic Code;
• Procedure Codes (describes the treatment or services rendered);
Assignment of Benefits, signed (if payment is to be made to the provider);
• Release of Information Statement, signed, and
SingleSource Self-Insured 58
Exhibit 'A'
• Explanation of Benefits (EOB) information if another plan is the primary payer.
This plan also recognizes the following actions and submission of forms as claims:
• A request by you for benefits through preauthorization in cases where use of preauthorization is
required in order to obtain a particular benefit.
• Requests by your formally-designated authorized representative for preauthorization in cases
where use of preauthorization is required in order to obtain a particular benefit. The plan will take
reasonable steps to determine whether an individual claiming to be acting on your behalf is, in fact,
validly empowered to do so under the circumstances, and the plan will require that you complete
and file a form identifying any person you authorize to act on your behalf with respect to a claim.
However, when inquiries by a health care provider relate to payments due to the provider-rather
than due to you-under participating provider contracts (where the health care provider has no
recourse against you for the amounts) such inquiries by a health care provider will not be
considered 'claims' by the plan.
• Requests for benefits (in the case of a claim involving urgent care) by a health care provider with
knowledge of your medical condition. For urgent care claims, you are not required to complete a
form and formally designate a health care provider as your representative with respect to a claim.
Claims must be submitted individually for each claimant. Please do not staple claims together. Send
completed information to:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extension 1009
cs@ pacificsou rce. com
If you have any questions regarding your eligibility, benefits or claims information, please call
PacificSource at: (888) 977-9299.
All claims for benefits must be submitted to the plan within 90 days of the date of service. If it is not
possible to submit a claim within 90 days, you should submit the claim as soon as possible. In some
cases the plan will accept the late claim. The plan, however, will not pay a claim that was submitted
more than one year after the date of service.
All submitted claims and appeals will fall into one of the categories described previously. The handling
of your initial claim or later appeal will be governed, in all respects, by the appropriate category of claim
or appeal, and each time your claim or appeal is examined, a new determination will be made regarding
the category into which the claim or appeal falls at that particular time.
Pre-service claims - Your plan subjects the receipt of benefits for some services or supplies to a
preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it
may in some case be conducted on a post-service basis. Unless a response is needed sooner due to
the urgency of the situation, a pre-service preauthorization review will be completed and notification
made to you and your medical provider as soon as possible, generally within two working days, but no
later than 15 days within receipt of the request.
Urgent care claims - If the time period for making a non-urgent care determination could seriously
jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain
that cannot be adequately managed without the care or treatment that is proposed, a preauthorization
review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours of
receipt of the request.
Concurrent care review - Inpatient hospital or rehabilitation facilities, skilled nursing facilities,
intensive outpatient, and residential behavioral healthcare require concurrent review for a benefit
determination with regard to an appropriate length of stay or duration of service. Benefit determinations
will be made as soon as possible but no later than one working day after receipt of all the information
necessary to make such a determination.
Post-service claims - A claim determination that involves only the payment of reimbursement of the
cost of medical care that has already been provided will be made as soon as reasonably possible but
no later than 30 days from the day after receiving the claim.
SingleSource Self-Insured 59
Exhibit 'A'
Retrospective review - A claim for benefits for which the service or supply requires a preauthorization
review but was not submitted for review on a pre-service basis will be reviewed on a retrospective basis
within 30 working days after receipt of the information necessary to make a claim determination.
Extension of time - Despite the specified timeframes, nothing prevents the member from voluntarily
agreeing to extend the above timeframes. Unless additional information is needed to process your
claim, PacificSource will make every effort to meet the timeframes stated above. If a claim cannot be
paid within the stated timeframes because additional information is needed, PacificSource will
acknowledge receipt of the claim and explain why payment is delayed. If PacificSource does not
receive the necessary information within 15 days of the delay notice, PacificSource will either deny the
claim or notify you every 45 days while the claim remains under investigation. No extension is permitted
for urgent care claims.
Extension of time - Unless additional information is needed to process your claim, the plan will make
every effort to meet the timeframes stated above. If a claim cannot be paid within the stated timeframes
because additional information is needed, PacificSource will acknowledge receipt of the claim and
explain why payment is delayed. If they do not receive the necessary information within 15 days of the
delay notice, they will either deny the claim or notify you every 45 days while the claim remains under
investigation.
Adverse benefit determinations - Any denial, reduction or termination of, or failure to provide or
make a payment for a benefit based on:
• A determination that the member is not eligible to participate in the plan.
• A determination that the benefit is not covered by the plan.
• The imposing of limits, such as preexisting condition or source-of-injury exclusions.
• A determination that the benefit is experimental, investigational or not medically necessary or
medically appropriate.
An adverse benefit determination made to reduce or deny benefits applied for a pre-service, post-
service, or concurrent care basis may be appealed in accordance with the plan's appeals procedures
described later in this section.
Incomplete Claims
If any information needed to process a claim is missing, the claim shall be treated as an incomplete
claim.
Other Incomplete Claims - If a pre-service or post-service claim is incomplete, the plan may deny the
claim or may take an extension of time, as described above. If the plan takes an extension of time, the
extension notice shall include a description of the missing information and shall specify a timeframe, no
less than 45 days, in which the necessary information must be provided. The timeframe for deciding the
claim shall be suspended from the date the extension notice is received by the claimant until the date
the missing necessary information is provided to the plan. If the requested information is provided, the
plan shall decide the claim within the extension period specified in the extension notice. If the requested
information is not provided within the time specified, the claim may be decided without that information.
If you fail to follow the plan's filing procedures because your request for benefits does not: 1) identify
the patient; 2) note a specific medical condition or symptom; 3) describe a specific treatment, service,
or product for which approval is requested; or 4) is not sent to the correct address, you will not have
submitted a claim. You will be notified orally, and/or by written notification if requested by the claimant,
within 24 hours, that you have failed to follow the filing procedures, and you will be reminded of the
proper filing procedures.
Notification of Benefit Determination
The plan will pay the benefit according to plan provisions. This may mean that less than 100% of your
claim is payable by the plan. In each case where the plan pays benefits or determines that it is not
responsible for your medical claim, you will receive an Explanation of Benefits which will outline the
basis for the plan's payment. If your claim is denied or payable at a level less than outlined in this
Summary Plan Description, you are entitled to appeal the decision under the rules governing adverse
benefit determination.
SingleSource Self-Insured 60
Exhibit'A'
Adverse Benefit Determination
• Written notification will be provided to you of the plan's adverse benefit determination (as defined in
the How To File A Claim section above) and will include the following:
• Information sufficient to identify the claim involved, including the date of service, the health care
provider, and the claim amount (if applicable), as well as how to obtain the diagnosis code, the
treatment code, and the corresponding meanings of these codes.
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
• A description of any additional material or information necessary to perfect the claim and why such
information is necessary;
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, disclose either (a) an explanation of the
scientific or clinical judgment applying the terms of the plan to the claimant's medical
circumstances, or (b) a statement that such explanation will be provided at no charge upon request;
• In the case of an urgent care claim, an explanation of the expedited review methods available for
such claims; and
• A statement regarding the availability of, and contact information for, any applicable office of health
insurance consumer assistance or ombudsman.
Notification of the plan's adverse benefit determination on an urgent care claim may be provided orally,
but written notification shall be furnished not later than three days after the oral notice.
You may call the Third Party Administrator at (888) 977-9299 to discuss the adverse benefit
determination if you have concerns. You may also express those concerns in writing and if needed,
may submit additional information that you believe would clarify any of the circumstances that lead to
the adverse benefit determination. Third Party Administrator will not consider any of these questions or
clarifications to be a formal appeal unless you specifically state it as such. The process for filing a
formal appeal is listed below.
Your Right to Appeal
You have the right to appeal an adverse benefit determination under these claims procedures. If you
choose to appeal the plan's adverse benefit determination, your appeal will be governed by rules that
assure you a full and fair review.
If you are denied benefits based upon the plan's finding that you are/were ineligible for benefits, the
denial of benefits gives you the opportunity to appeal the plan's decision.
If the plan decides to reduce or terminate benefits for your previously-approved course of treatment, the
plan's decision will be treated as an adverse benefit determination, and the plan will provide you
reasonable advance notice of the reduction or termination to allow you to appeal the plan's decision
before the benefit reduction or termination takes place. If you decide to appeal the plan's decision, you
must follow the rules for appealing a plan's decision.
No lawsuit can be instituted until the claimant has exhausted the plan's internal and external claims
review and appeals procedures. No lawsuit can be instituted more than one year after the date of the
notice to the claimant that a claim, appeal has been denied. ,
Appealing an Initial Claim Determination - You must submit a written request to the plan within 180
days of receipt of an adverse benefit determination in order to initiate an appeal. An oral request for
review is acceptable for urgent care claims and may be made by calling the Third Party Administrator at
(888) 977-9299 and asking the plan to register your oral appeal.
SingleSource Self-Insured 61
Exhibit 'A'
When you appeal an adverse benefit determination, the plan will provide a full and fair review which will
include the following features:
• You will have the opportunity to submit written comments, documents, records, and other
information related to the claim.
• At your request (and free of charge), you will be provided with reasonable access to (and copies oi)
all documents, records, and other information relevant to your claim for benefits. Included in this
category are any documents, records or other information in your claim file, whether or not those
materials were relied upon by the plan in making its adverse benefit determination. You also have
the right to review documentation showing that the plan followed its own internal processes for
ensuring appropriate decision making.
• The review of your claim will take into account all comments, documents and other information
without regard to whether such information was submitted or considered in the initial benefit
determination.
• Any appeal of an adverse benefit determination will not give deference to the initial decision on your
claim, and the review will be conducted by a designated plan representative who did not make the
original determination and does not report to the plan representative who made the original
determination.
• In deciding an appeal of any adverse benefit determination that is based on a medical judgment
(including determinations with regard to whether a particular treatment, drug, or other item is
experimental, investigational, or not medically necessary or medically appropriate), the designated
plan representative will consult with a health care professional who has appropriate training and
experience in the particular field of medicine involved in the medical judgment. This health care
professional will not be the same professional who was originally consulted in connection with the
adverse determination; neither will this health care professional report to the health care
professional who was consulted in connection with the adverse determination. The plan will uphold
the findings of the independent review in responding to the appeal.
• The plan will identify medical or vocational experts whose advice was obtained on behalf of the
plan in connection with an adverse benefit determination of your claim, whether or not that advice
was relied upon in making the benefit determination.
You must first follow this appeal process before taking any outside legal action. After you submit the
claim for appeal, the plan will make a decision on your appeal as follows:
Appeal of Urgent Care Claims -The plan's expedited appeal process for urgent care claims will allow
you to request (orally or in writing) an expedited appeal, after which, all necessary information, including
the plan's benefit determination on review, will be transmitted between the plan and you by telephone,
fax, or other expeditious method. You will be notified (in writing or electronically) of the benefit
determination as soon as possible, but not later than 72 hours after the plan receives the request for
review of the prior benefit determination. For urgent care claims you may also be able to request an
independent external review take place at the same time as you pursue the plan's internal appeal
process.
Appeal of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will be notified (in
writing or electronically) of the benefit determination within a reasonable period of time appropriate to
the medical circumstances, but not later than 30 days.
Appeal of Concurrent Care Claims - For concurrent care claims, you will be notified (in writing or
electronically) of the benefit determination with reasonable advance notice before the benefit reduction
or termination takes place.
Appeal of Post-Service Claims - For post-service claims, you will be notified (in writing or
electronically) of the benefit determination within a reasonable period of time, but not later than 60 days.
Denial of Claim on Appeal - If your appealed claim is denied, the plan will send you written or
electronic notification that explains why your appealed claim was denied and shall include the following:
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) bn which the determination is based;
SingleSource Self-Insured 62
Exhibit'A'
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, the plan will disclose either (a) an
explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's
medical circumstances, or (b) a statement that such explanation will be provided at no charge upon
request; and
• A statement indicating your right to receive, upon request (and free of charge), reasonable access
to (and copies of) all documents, records, and other information relevant to the determination.
Included in this category are any documents, records or other information in your claim file, whether
or not those materials were relied upon by the plan in making its adverse determination.
Additional Level of Review - If you are dissatisfied with the outcome of your appeal, you may request
an additional review. To initiate this review you should follow the same process required for an appeal.
You must submit a written request for additional review within 60 days following the receipt of the
appeal decision.
When you submit a request for additional review of an adverse benefit determination, the plan will
provide a full and fair review which will include the following features:
• You will have the opportunity to submit written comments, documents, records, and other
information related to the claim.
• At your request (and free of charge), you will be provided with reasonable access to (and copies of)
all documents, records, and other information relevant to your claim for benefits. Included in this
category are any documents, records or other information in your claim file, whether or not those
materials were relied upon by the plan in making its adverse benefit determination. You also have
the right to review documentation showing that the plan followed its own internal processes for
ensuring appropriate decision making.
• The review of your claim will take into account all comments, documents and other information
without regard to whether such information was submitted or considered in the initial adverse
benefit determination.
• Additional review will not afford deference to the appeal determination, and the review will be
conducted by a designated plan representative who did not make the original determination and
does not report to the plan representative who made the original determination.
• In deciding an appeal of any adverse benefit determination that is based on a medical judgment
(including determinations with regard to whether a particular treatment, drug, or other item is
experimental, investigational, or not medically necessary or medically appropriate), the designated
plan representative will consult with a health care professional who has appropriate training and
experience in the particular field of medicine involved in the medical judgment. This health care
professional will not be the same professional who was originally consulted in connection with the
adverse determination; neither will this health care professional report to the health care
professional who was consulted in connection with the adverse determination. The plan will uphold
the findings of the independent review in responding to the appeal.
• The plan will identify medical or vocational experts whose advice was obtained on behalf of the
plan in connection with an adverse benefit determination of your claim, whether or not that advice
was relied upon in making the benefit determination.
After you submit the claim for additional review, the plan will make a decision on your appeal as follows:
Additional Review of Urgent Care Claims - The plan's expedited additional review process for urgent
care claims will allow you to request (orally or in writing) an expedited review, after Which, all necessary
information, including the plan's benefit determination on review, will be transmitted between the plan
and you by telephone, fax, or other expeditious method. You will be notified (in writing or electronically)
of the benefit determination as soon as possible, but not later than 72 hours after the plan receives the
request for the review.
Additional Review of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will
be notified (in writing or electronically) of the review outcome within a reasonable period of time
appropriate to the medical circumstances, but not later than 30 days.
SingleSource Self-Insured 63
Exhibit'A'
Additional Review of Concurrent Care Claims - For concurrent care claims, you will be notified (in
writing or electronically) of the review outcome with reasonable advance notice before the benefit
reduction or termination takes place.
Additional Review of Post-Service Claims - For post-service claims, you will be notified (in writing or
electronically) of the review outcome within a reasonable period of time, but not later than 60 days.
Denial of Claim after Additional Review - If after your request for additional review the claim is
denied, the plan will send you written or electronic notification that explains why the additional review
upheld the denial and shall include the following:
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, the plan will disclose either (a) an
explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's
medical circumstances, or (b) a statement that such explanation will be provided at no charge upon
request; and
• A statement indicating your right to receive, upon request (and free of charge), reasonable access
to (and copies of) all documents, records, and other information relevant to the determination.
Included in this category are any documents, records or other information in your claim file, whether
or not those materials were relied upon by the plan in making its adverse determination.
Independent External Review - You may have the right to have your case reviewed by an external
independent review organization. Only decisions that are based on issues related to medical necessity,
medical appropriateness, health care setting, level of care, or effectiveness of a covered benefit may be
appealed to an external independent review organization. The plan must contract with at least three
different independent external review organizations and must rotate between them on a random or
circulating basis.
Your request for an independent review must be made in writing to PacificSource within 180 days of the
date of the final internal adverse benefit determination. You may include additional written information,
which will be included with the documents PacificSource provides to the independent review
organization.
A final decision made by an independent review organization is binding on the Plan Sponsor. This
decision is also binding on you, except to the extent other remedies are available under state or federal
law.
In certain instances you may be able to request an expedited review process, such as when the
timeframe for completion of the internal appeals process would seriously jeopardize the life or health of
the claimant or their ability to regain maximum function, or if the final adverse benefit determination
concerns an admission, availability of care, continued stay or health care service for which the claimant
received emergency services, but has not been discharged from a facility.
Resources For Information And Assistance
Assistance in Other Languages
Members who do not speak English may contact PacificSource's Customer Service Department for
assistance. They can usually arrange for a multilingual staff member or interpreter to speak with them in.
their native language.
Information Available from PacificSource
PacificSource makes the following written information available to you free of charge. You may contact
their Customer Service Department by phone, mail, or email to request any of the following:
• A directory of participating healthcare providers under your plan
SingleSource Self-Insured 64
Exhibit'A'
• Information about PacificSource's drug formulary
• A copy of PacifcSource's annual report on complaints and appeals
• A description (consistent with risk-sharing information required by the Centers for Medicare and
Medicaid Services, formerly known as Health Care Financing Administration) of any risk-sharing
arrangements PacificSource has with providers
• A description of PacificSource's efforts to monitor and improve the quality of health services
• Information about how PacificSource checks the credentials of PacificSource's network providers
and how you can obtain the names and qualifications of your healthcare providers
• Information about PacificSource's preauthorization procedures
• Information about any healthcare plan offered by the Plan Sponsor
Information Available from the Oregon Insurance Division
The following consumer information is available from the Oregon Insurance Division:
• The results of all publicly available accreditation surveys
• A summary of PacificSource's health promotion and disease prevention activities
• Samples of the written summaries delivered to PacificSource policyholders
• An annual summary of grievances and appeals against PacificSource
• An annual summary of PacificSource's quality assessment activities
• An annual summary of the scope of PacificSource's provider network and accessibility of
healthcare services
You can request this information by contacting the Oregon Insurance Division by writing to the Oregon
Insurance Division, Consumer Advocacy Unit, PO Box 14489, Salem, OR 97309-0405 or by phone at
(503) 947-7984, or the toll-free message line at (888) 877-4894, on the Internet at
http://insurance.oregon.gov/consumer/consumer.html, or by email at cp.ins@state.or.us.
Plan Sponsor's Discretionary Authority; Standard of Review
The Plan Sponsor is the sole fiduciary of the plan, and exercises all discretionary authority and control
over the administration of the plan and the management and disposition of plan assets. Benefits under
the plan will be paid only if the Plan Sponsordecides, in its discretion, that the member or beneficiary is
entitled to such benefits. Any construction of the terms of any plan document and any determination of
fact adopted by the Plan Sponsorshall be final and legally binding on the parties. A court of law or
arbitrator reviewing any fiduciary's decision, including one relating the plan interpretation or a benefit
claim, must consider only the documents, testimony and other evidence that were presented to the
fiduciary at the time the fiduciary made the decision. In addition, the court or arbitrator must use the
'arbitrary and capricious' standard of review. That is, the fiduciary's determination can be reversed only
if it was made in bad faith, is not supported by substantial evidence or is erroneous as to a question of
law.
The Plan Sponsor may hire someone to perform claims processing and other specified services in
relation to the plan. Any such contractor will not be a fiduciary of the plan and will not exercise any of
the discretionary authority and responsibility granted to the Plan Sponsor, as described above.
Coordination of Benefits
Coordinating with Other Group Health Plans - When benefits are coordinated, one plan pays
benefits first (the 'primary coverage') and the other plan pays benefits second (the 'secondary
coverage').
When you and/or your dependents are covered under more than one group health plan, the combined
benefits payable by this plan and all other group plans will not exceed 100% of the eligible expense
incurred by the individual. The plan assuming primary payer status will determine benefits first without
regard to benefits provided under any other group health plan.
SingleSource Self-Insured 65
Exhibit'N
Note: If your primary and secondary coverage both include a deductible, you will be required to satisfy
each of those deductibles before benefits will be paid.
There are two types of Coordination of Benefits -'True' Coordination of Benefits and Non-Duplicating
Coordination of Benefits (also called Integration of Benefits.) See the Medical Benefit Summary to
determine if your plan offers True Coordination of Benefits or Non-Duplicating/Integration of Benefits.
For True Coordination of Benefits, the primary plan will pay benefits first, subject to any deductibles,
copayments and coinsurance. The remaining balance will be passed on to the secondary payer. When
this plan is the secondary payer, the balance of eligible expenses will be applied as if it was a new
claim under this plan. Deductibles, copayments and coinsurance relevant to this plan will be subtracted
from the amount before paying the remainder.
For Non-Duplicating Coordination of Benefits/Integration of Benefits, the primary plan will pay
benefits first, subject to any deductibles, copayments and coinsurance. The remaining balance will be
passed on to the secondary payer. When this plan is the secondary payer, it will reimburse the balance
of remaining eligible expenses, not to exceed normal plan liability if this plan had been primary. This
means that if the primary payer has already paid as much as or more than this plan would have paid
had this plan been primary, there will be no additional payment made.
Government Programs and Other Group Health Plans -The term group health plan, as it relates to
coordination of benefits, includes the government programs Medicare, Medicaid and TriCare. The
regulations governing these programs take precedence over the determination of benefits under this
plan. For example, in determining the benefits payable under the plan, the plan will not take into
account the fact that you or any eligible dependent(s) are eligible for or receive benefits under a
Medicaid plan.
The term group health plan also includes all group insurance and group subscriber contracts, such as
union welfare plans.
Order of Payment When Coordinating with Other Group Health Plans
• If the other plan does not include 'coordination of benefits,' that plan is primary and this plan is
secondary.
• If you are covered as an employee on one plan and a dependent on another, your Plan Sponsor's
plan is primary.
• When a child is covered under both parents' policies and the parents are either married or are living
together (regardless of whether or not they have ever been married):
- The parent whose birthday falls first in a benefit year has the primary plan; or
- If both parents have the same birthday, the parent who has been covered the longest has the
primary plan.
• When a child is covered under both parents' plans and the parents are divorced, separated, or not
living together (regardless of whether or not they have ever been married):
- If a court order specifies that one parent is responsible for the child's healthcare expenses,
the mandated parent's coverage is primary regardless of custody.
- If a court order specifies that both parents are responsible for the child's healthcare
expenses, the parent whose birthday falls first in a benefit year has the primary plan. If both
parents have the same birthday, the parent who has been covered the longest has the
primary plan.
- If a court order specifies that both parents have joint custody without specifying that one
parent has responsibility for the child's healthcare expenses, the parent whose birthday falls
first in a benefit year has the primary plan. If both parents have the same birthday, the parent
who has been covered the longest has the primary plan.
- If there is no court order, the order of benefits for the child are as follows:
o The custodial parent's coverage is primary,
o The spouse of the custodial parent's coverage pays second;
o The natural parent without custody's coverage pays third; and
SingleSource Self-Insured 66
Exhibit 'A'
o The spouse of the natural parent without custody's coverage pays fourth.
• If a plan covers you as an active employee or a dependent of an active employee, that plan is
primary. Another plan covering you as inactive, laid off, or retired is secondary.
• When this plan covers you or your dependent pursuant to COBRA or under a right of continuation
pursuant to other federal law, the plan covering you or your dependent as an employee, member,
subscriber, or retiree or covering you or your dependent as a dependent of an employee, member,
subscriber or retiree is the primary plan and this plan's coverage is the secondary plan.
• If none of these rules apply, the coverage that has been in place longest is primary.
Most insurers or administrators send you an explanation of benefits, or EOB, when they pay a claim. If
your other plan's coverage is primary, send PacificSource the other plan's EOB with your original bill
and they will process your claim. If you receive more than you should when your benefits are
coordinated, you will be expected to repay any over-payment to the plan.
Right to Make Payments to Other Organizations - Whenever payments, which should have been
made by this plan, have been made by any other plan(s), this plan has the right to pay the other plan(s)
any amount necessary to satisfy the terms of this coordination of benefits provision. Amounts paid will
be considered benefits paid under this plan and, to the extent of such payments, the plan will be fully
released from any liability regarding the person for whom payment was made.
Automobile Insurance - This plan provides benefits relating to medical expenses incurred as a result
of an automobile accident on a secondary basis only. Benefits payable under this plan will be
coordinated with and secondary to benefits provided or required by any no-fault automobile insurance
statute, whether or not a no-fault policy is in effect, and/or any other automobile insurance.
Any benefits provided by this plan will be subject to the plan's reimbursement and/or subrogation
provisions.
OTHER IMPORTANT PLAN PROVISIONS
Assignment of Benefits
All benefits payable by the plan are automatically assigned to the provider of services or supplies,
unless evidence of previous payment is submitted with the claim form. However, the plan reserves the
right to reimburse the member, the provider, or both jointly. Payments made in accordance with an
assignment are made in good faith and release the plan's obligation to the extent of the payment.
Payments will also be made in accordance with any assignment of rights required by a state Medicaid
plan.
Members are expressly prohibited from assigning any right to payment of benefits under a Benefit
Program, including this plan. No attempts at assignment of any such expenses under a Benefit
Program will be recognized. Except as may be expressly prescribed in an agreement to which the Plan
Sponsor is a party, nothing contained in any written designation of coverage under a Benefit Program
will make the Benefit Program, or the Plan Sponsor or any other employer, liable to any third-party to
whom a member may be liable for medical care, treatment or services.
Proof of Loss
The Plan Sponsor has the right to require a claimant to undergo physical or psychological examinations
relating to the claimant's illness, injury or condition as often as the Plan Sponsor deems reasonably
necessary while the claim for benefits is pending. The Plan Sponsor also has the right to require an
autopsy in case of death (where not prohibited by law).
No Verbal Modifications of Plan Provisions
No verbal statement made by anyone involved in administering this plan can waive any of the terms or
conditions of this plan or prevent the Plan Sponsorfrom enforcing any provision of this plan. Waivers
are valid only if they are contained in a written instrument signed by an authorized individual on behalf
of the Plan Sponsor. Any such written waiver will be valid only as to the specific plan, term or condition
set forth in the written instrument. Unless specifically stated otherwise, a written waiver will be valid only
for the specific claim involved at the time, and will not be a continuing waiver of the term or condition in
the future.
SingleSource Self-Insured 67
Exhibit'A'
Reimbursement to the Plan
This section applies whenever another party (including your own insurer under an automobile or other
policy) is legally responsible or agrees to compensate you or your dependent, by settlement, verdict or
otherwise, for an illness or injury. In that case, you or your dependent (or the legal representatives,
estate or heirs of either you or your dependent), must promptly reimburse the plan for any benefits it
paid relating to that illness or injury, up to the full amount of the compensation received from the other
party (regardless of how that compensation may be characterized and regardless of whether you or
your dependent have been made whole). If the plan has not yet paid benefits relating to that illness or
injury, the plan may reduce or deny future benefits on the basis of the compensation received by you or
your dependent.
Benefits relating to such illness or injury will not be payable by the plan until you sign and return a
statement, provided by the plan, acknowledging your obligation to reimburse the plan under this
provision. That obligation will arise upon the payment of any plan benefits relating to the illness or
injury, whether or not you sign such a statement.
You or your dependent must cooperate with the plan and its authorized representatives, and must sign
and deliver such documents as the plan or its agents reasonably request to protect the plan's right of
reimbursement. You or your dependent must also provide any relevant information and take such
actions as the plan or its agents reasonably request to assist the plan in making a full recovery of the
reasonable value of the benefits provided. You or your dependent must not take any action that
prejudices the plan's right of reimbursement.
In order to secure the rights of the plan under this section, you or your dependent hereby: (1) grant to
the plan a first priority lien against the proceeds of any such settlement, verdict or other amounts
received by you or your dependent; and (2) assign to the plan any benefits you or your dependent may
have under any automobile policy or other coverage, to the extent of the plan's claim for
reimbursement.
The reimbursement required under this provision will not be reduced to reflect any costs or attorneys'
fees incurred in obtaining compensation unless separately agreed to, in writing, by the Plan Sponsor, in
the exercise of its sole discretion.
This plan expressly disavows and repudiates the make whole doctrine, which, if applicable, would
prevent the plan from receiving a recovery unless a member has been 'made whole' with regard to
illness or injury that is the responsibility of a third party. This plan also expressly disavows and
repudiates the common fund doctrine, which, if applicable, would require the plan to pay a portion of the
attorney fees and costs expended in obtaining a recovery. These doctrines have no application to this
plan, since the plan's recovery rights apply to the first dollars payable by a third party.
Subrogation
This section applies whenever another party (including your own insurer under an automobile or other
policy) is legally responsible or agrees to compensate you or your dependent for you or your
dependent's illness or injury and the plan has paid benefits related to that illness or injury.
The plan is subrogated to all of the rights of you or your dependent against any party liable for you or
your dependent's illness or injury to the extent of the reasonable value of the benefits provided to you or
your dependent under the plan. The plan may assert this right independently of you or your dependent.
You and your dependent are obligated to cooperate with the plan and its authorized representatives in
order to protect the plan's subrogation rights. Cooperation means providing the plan or its agents with
any relevant information requested by them, signing and delivering such documents as the plan or its
agents reasonably request to secure the plan's subrogation claim, and obtaining the consent of the plan
or its agents before releasing any party from liability for payment of medical expenses.
If you or your dependent enters into litigation or settlement negotiations regarding the obligations of
other parties, you or your dependent must not prejudice, in any way, the subrogation rights of the plan
under this section.
SingleSource Self-Insured 68
Exhibit 'A'
The costs of legal representation of the plan in matters related to subrogation will be borne solely by the
plan. The costs of legal representation of you or your dependent must be borne solely by you or your
dependent.
Recovery of Excess Payments
Whenever payments have been made in excess of the amount necessary to satisfy the provisions of
this plan, or were made in error by the plan, the plan has the right to recover these payments from any
individual (including yourself), insurance company or other organization to whom the payments were
made or to withhold payment, if necessary, on future benefits until the overpayment is recovered. If
excess or erroneous payments were made for services rendered to your dependent(s), the plan has the
right to withhold payment on your future benefits until the overpayment is recovered.
Further, whenever payments have been made based on fraudulent information provided by you, the
plan will exercise all available legal rights, including its right to withhold payment on future benefits, until
the overpayment is recovered.
In the same manner, if the plan applies medical expenses to the plan deductible that would not
otherwise be reimbursable under the terms of this policy, the plan may deduct a like amount from the
accumulated deductible amounts and/or recover payment of medical expenses that would have
otherwise been applied to the deductible. The fact that a medical expense was applied to the plan's
deductible, or that a drug was provided under the plan's prescription drug program, does not in itself
create an eligible expense or infer that benefits will continue to be provided for an otherwise excluded
condition.
Right To Receive and Release Necessary Information
The plan may, without the consent of or notice to any person, release to or obtain from any organization
or person, information needed to implement plan provisions, including medical information. When you
request benefits, you must either furnish or authorize the release of all the information required to
implement plan provisions. Your failure to fully cooperate will result in a denial of the requested benefits
and the plan will have no further liability for such benefits.
Under normal conditions, benefits are payable to the provider of services or supplies, unless evidence
of previous payment is submitted with the claim form. If conditions exist under which a valid release or
assignment cannot be obtained, the plan may make payment to any individual or organization that has
assumed the care or principal support for you and is equitably entitled to payment. The plan must make
payments to your separated/divorced spouse, state child support agencies or Medicaid agencies if
required by a qualified medical child support order (QMCSO) or state Medicaid law.
The plan may also honor benefit assignments made prior to your death in relation to remaining benefits
payable by the plan.
Any payment made by the plan in accordance with this provision will fully release the plan of its liability
to you.
Reliance on Documents and Information
Information required by the Plan Sponsor or PacificSource may be provided in any form or document
that the Plan Sponsor and PacificSource considers acceptable and reliable. The Plan Sponsor and
PacificSource relies on the information provided by you and others when evaluating coverage and
benefits under the plan. All such information, therefore, must be accurate, truthful and complete. The
Plan Sponsor and PacificSource is entitled to conclusively rely upon, and will be protected for any
action taken in good faith in relying upon, any information provided to the Plan Sponsor or
PacificSource. In addition, any fraudulent statement, omission or concealment of facts,
misrepresentation, or incorrect information may result in the denial of the claim, cancellation or
rescission of coverage, or any other legal remedy available to the plan.
No Waiver
The failure of the Plan Sponsorto enforce strictly any term or provision of this plan will not be construed
as a waiver of such term or provision. The Plan Sponsor reserves the right to enforce strictly any term
or provision of this plan at any time.
SingleSource Self-Insured 69
Exhibit'A'
Physician/Patient Relationship
This plan is not intended to disturb the physician/patient relationship. Physicians, practitioners and other
health care providers are not agents or delegates of the Plan Sponsor, or the Third Party Administrator.
Nothing contained in this plan will require you or your dependent to commence or continue medical
treatment by a particular provider. Further, nothing in this plan will limit or otherwise restrict a physician
or practitioner's judgment with respect to the physician or practitioner's ultimate responsibility for patient
care in the provision of medical services to you or your dependent.
Plan not responsible for Quality of Health Care
You and your enrolled dependents have the right to select your health care provider. Neither the plan,
your Plan Sponsor, nor Third Party Administrator is responsible for the quality of care received and
cannot be held liable for any claim or damages connected with injuries suffered while receiving health
services or supplies.
Plan is not a Contract of Employment
Nothing contained in this plan will be construed as a contract or condition of employment between the
Plan Sponsor and any employee. All employees are subject to discharge to the same extent as if this
plan had never been adopted.
Right to Amend or Terminate Plan
Plan Sponsor reserves the right to amend, modify or terminate the plan in any manner, for any reason,
at any time.
If changes occur, your Plan Sponsor will notify you of changes to your plan.
If your health plan terminates and your Plan Sponsor does not replace the coverage with another group
policy, your Plan Sponsor is required by law to advise you in writing of the termination. When this plan
terminates, your Plan Sponsor will notify you about any available options for you to continue your
coverage.
The Plan Sponsor may pay your medical claims if a workers' compensation claim has been denied on
the basis that the illness or injury is not work related, and the denial is under appeal. But before
PacificSource does that, you must sign a written agreement to reimburse the Plan Sponsor any money
you recover from the workers' compensation coverage.
Rescissions
The Plan Sponsor or PacificSource may not rescind the coverage of a member unless the member, or
person seeking coverage on behalf of the member, performs an act, practice or omission that
constitutes fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms
of this plan and the Plan Sponsor or PacificSource gives the member a 30-day prior written notice.
PacificSource may not rescind the policyholder's group health benefit plan unless the policyholder, or
representative of the policyholder, performs an act, practice or omission that constitutes fraud or makes
an intentional misrepresentation of a material fact as prohibited by the terms of this plan and
PacificSource gives a 30-day prior written notice to all member covered under the plan. Rescissions do
not include a cancellation or discontinuance of coverage that is prospective or to the extent it is
attributable to a failure to timely pay required contributions towards the cost of coverage.
Applicable Law
This is a self-insured benefit plan. As such, Federal law preempts State law and jurisdiction. To the
extent not preempted by federal law, the laws of the state of Oregon shall apply.
PRIVACY AND CONFIDENTIALITY
This notice is intended to bring the City of Ashland Employee Benefit Plan into compliance with the
requirements of Section 164.504(f) of the Health Insurance Portability and Accountability Act of 1996
and its implementing regulations, 45 C.F.R. parts 160 through 164 (the'HIPAA Privacy Rule') by
SingleSource Self-Insured 70
Exhibit 'A'
establishing the conditions under which the Plan Sponsor will receive, use and/or disclose protected
health information.
Permitted Disclosures of Protected Health Information to the Plan Sponsor
Subject to the conditions of the 'No Disclosure of Protected Health Information to the Employer Without
Certification by Employer' and 'Conditions of Disclosure of Protected Health Information to the
Employer', the plan (and any third party administrator or business associate acting on behalf of the
plan) may disclose individuals' protected health information to the Plan Sponsorfor the Plan Sponsor or
PacifcSource to carry out plan administration functions. The plan (and any third party administrator or
business associate acting on behalf of the plan) may not disclose individuals' protected health
information to the Plan Sponsor for employment-related actions and decisions or in connection with any
other benefit or employee benefit plan of the Plan Sponsor.
No Disclosure of Protected Health Information to the Plan Sponsorwithout Certification by Plan
Sponsor
Except as provided below in'Disclosures of Summary Health Information and Enrollment/Disenrollment
Information to the Employer,' with respect to the plan's disclosure of summary health information and
enrollment/disenrollment information, the plan will not disclose protected health information to any
employee of the Plan Sponsor.
Conditions of Disclosure of Protected Health Information to the Plan Sponsor
The Plan Sponsor certifies that the plan has been amended to incorporate this section and agrees to
the following restrictions and conditions of receiving protected health information (other than summary
health information or enrollment/disenrollment information as explained in 'Disclosures of Summary
Health Information and Enrollment/Disenrollment Information to the Plan Sponsor below). The Plan
Sponsorshall:
• Not use or further disclose the protected health information other than as permitted or required
herein or as required by law.
• Ensure that any agent(s), including a subcontractor, to whom it provides protected health
information received from the plan agrees to the same restrictions and conditions that apply to the
Plan Sponsor with respect to such protected health information.
• Not use or disclose protected health information for employment-related actions and decisions or in
connection with any other benefit or employee benefit plan of the Plan Sponsor.
• Report to the plan any use or disclosure of protected health information that is inconsistent with the
uses or disclosures provided for of which the Plan Sponsor becomes aware.
• Make available protected health information to comply with an individual's right to access protected
health information in accordance with 45 C.F.R. Section 164.524.
• Make available protected health information for amendment and incorporate any amendments to
protected health information in accordance with 45 C.F.R. Section 164.526.
• Make available the information required to provide an accounting of disclosures in accordance with
45 C.F.R.§164.528.
• Make its internal practices, books and records relating to the use and disclosure of protected health
information received from the plan available to the Secretary of the Department of Health and
Human Services for purposes of determining compliance by the plan with the HIPAA Privacy Rule.
• If feasible, return or destroy all protected health information received from the plan that the Plan
Sponsor still "Maintains in any form and retain no copies of such information when no longer needed
for the purpose for which disclosure was made, except that, if such return or destruction is not
feasible, the Plan Sponsorwill limit further uses and disclosures to those purposes that make the
return or destruction of the information infeasible.
• Ensure that the required adequate separation, described in 'Required Separation Between the Plan
and the Plan Sponsor' below, is established and maintained.
SingleSource Self-Insured 71
Exhibit'A'
Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the
Plan Sponsor
• The plan (or a third party administrator of the plan) may disclose summary health information to the
Plan Sponsorwithout the need to comply with the conditions and restrictions of 'No Disclosure of
Protected Health Information to the Plan Sponsor Without Certification by Plan Sponsor and
'Conditions of Disclosure of Protected Health Information to the Plan Sponsor, if the Plan Sponsor
requests the summary health information for the purpose of:
- Obtaining premium bids from health plans (including health insurance issuers) for providing
health insurance coverage under the plan; or
- Modifying, amending, or terminating the plan
• The plan (or a third party administrator of the plan) may disclose information on whether the
individual is participating in the group health plan, or is enrolled in or has disenrolled from the plan
without the need to comply with the conditions and restrictions of 'No Disclosure of Protected
Health Information to the Plan Sponsor Without Certification by Plan Sponsor and'Conditions of
Disclosure of Protected Health Information to the Plan Sponsor
Required Separation between the Plan and the Plan Sponsor
• The following classes of employees or other persons under the control of the Plan Sponsor will
have access to protected health information received from the plan (or from a health insurance
issuer with respect to the plan):
- Human Resources
• No other persons shall have access to protected health information. The listed classes of
employees or other persons under the control of the Plan Sponsorwill have access to protected
health information solely to perform the plan administration functions that the Plan Sponsor
performs for the plan. They will be subject to disciplinary action and/or sanctions (including
termination of employment or affiliation with the Plan Sponsor) for any use or disclosure of
protected health information in violation of the provisions of this plan.
DEFINITIONS
Wherever used in this plan, the following definitions apply to the terms listed below, and the masculine
includes the feminine and the singular includes the plural. For the purpose of this plan, 'employee'
includes the Plan Sponsor when covered by this plan. Other terms are defined where they are first used
in the text.
Abutment is a tooth used to support a prosthetic device (bridges, partials or overdentures). With an
implant, an abutment is a device placed on the implant that supports the implant crown.
Accident means an unforeseen or unexpected event causing injury that requires medical attention.
Actively at work or active employment means that an employee is performing in the customary
manner all of the regular duties of his/her occupation with the Plan Sponsor, either at one of the Plan
Sponsors regular places of business or at some location to which the Plan Sponsors business requires
the employee to travel to perform his/her regular duties assigned by the Plan Sponsor. An employee is
also considered to be actively at work on each day of a regular paid vacation or non-work day, but only
if the employee is performing in the customary manner all of the regular duties of the employee's
occupation with the Plan Sponsor on the immediately preceding regularly scheduled workday.
Advanced diagnostic imaging means diagnostic examinations using CT scans, MRIs, PET scans,
CATH labs, and nuclear cardiology studies. t.
Adverse benefit determination means a denial, reduction, or termination of a healthcare item or
service, or a failure or refusal to provide or to make a payment in whole or in part for a healthcare item
or service, that is based on the Plan Sponsors or PacificSource's:
• Denial of eligibility for or termination of enrollment in a health benefit plan;
• Rescission or cancellation of a policy or coverage;
• Imposition of a source-of-injury exclusion, network exclusion, annual benefit limit or other limitation
on otherwise covered items or services;
SingleSource Self-Insured 72
Exhibit'A'
• Determination that a healthcare item or service is experimental, investigational, or not medically
necessary, effective, or appropriate; or
• Determination that a course or plan of treatment that a member is undergoing it an active course of
treatment for purposes of continuity of care under ORS 743.854.
Advantage Essential Network is the exclusive provider network that provides dental care to members
under this plan.
Allowable fee is the dollar amount established by the plan for reimbursement of charges for specific
services or supplies provided by nonparticipating providers. The plan uses several sources to
determine the allowable amount. Depending on the service or supply and the geographical area in
which it is provided, the allowable amount may be based on data collected from the Centers for
Medicare and Medicaid Services (CMS), Viant Health Payment Solutions, other nationally recognized
databases, or PacificSource.
Where the provider network is deemed adequate, the allowable fee for professional services is based
on PacificSource's standard participating provider reimbursement rate or a contracted reimbursement
rate. Outside the PacificSource service area and in areas where the participating provider network is
not deemed adequate, the allowable fee is based on the usual, customary, and reasonable charge
(UCR) at the 85th percentile. UCR is based on data collected for a geographic area. Provider charges
for each type of service are collected and ranked from lowest to highest. Charges at the 85th position in
the ranking are considered to be the 85th percentile.
Alveolectomy is the removal of bone from the socket of a tooth.
Amalgam is a silver-colored material used in restoring teeth.
Ambulatory surgical center means a facility licensed by the appropriate state or federal agency to
perform surgical procedures on an outpatient basis.
Ancillary Services means service rendered in connection with Inpatient or Outpatient care in a
Hospital or in connection with a medical emergency, such as assistant surgeon, anesthesiology,
ambulance, pathology and radiology.
Approved clinical trials are Phase I, II, III, or IV clinical trials for the prevention, detection, or treatment
of cancer or another life-threatening condition or disease.
Authorized representative is an individual who by law or by the contest of a person may act on behalf
of the person.
Benefit year means the 12-month period beginning on each January 1 and ending on the next
December 31.
Cardiac rehabilitation refers to a comprehensive program that generally involves medical evaluation,
prescribed exercise, and cardiac risk factor modification. Education, counseling, and behavioral
interventions are sometimes used as well. Phase I refers to inpatient services that typically occur during
hospitalization for heart attack or heart surgery. Phase II refers to a short-term outpatient program,
usually involving ECG-monitored exercise. Phase III refers to a long-term program, usually at home or
in a community-based facility, with little or no ECG monitoring.
Cast restoration includes crowns, inlays, onlays, and other restorations made to fit a patient's tooth
that are made at a laboratory and cemented onto the tooth.
Certificate of Creditable Coverage means a certificate or other documentation that shows previous
health insurance coverage for a member and can be used to reduce the length of any pre-existing
condition exclusions under a plan. See Creditable coverage.
Chemical dependency means the addictive relationship with any drug or alcohol characterized by
either a physical or psychological relationship, or both, that interferes with the individual's social,
psychological, or physical adjustment to common problems on a recurring basis. Chemical dependency
does not include addiction to, or dependency on, tobacco products or foods.
Claims Administrator means the organization selected by the City of Ashland to provide claims
processing and adjudication under their plans. The Claims Administrator for their medical, vision and
pharmacy coverage is PacificSource.
Composite resin is a tooth-colored material used in restoring teeth.
Contracted amount means the amount that participating providers have contracted to accept as
payment in full for covered expenses under the plan.
SingleSource Self-Insured 73
Exhibit 'A'
Copayment or coinsurance is the out-of-pocket amount a member is required to pay to a provider.
Creditable coverage means a member's prior health coverage that meets the following criteria:
• There was no more than a 63-day break between the last day of coverage under the previous
policy and the first day of coverage under this policy. The 63-day limit excludes the Plan Sponsor's
eligibility waiting period.
• The prior coverage was one of the following types of insurance: group coverage (including Federal
Employee Health Benefit Plans and Peace Corps), individual coverage (including student health
plans), Medicaid, Medicare, TRICARE, Indian Health Service or tribal organization coverage, state
high-risk pool coverage, and public health plans.
Curettage is the scraping and cleaning of the walls of a real or potential space, such as a gingival
pocket or bone, to remove pathological material.
Custodial Care means non-medical care that is primarily to assist with activities of daily living, whether
or not the care is administered by a licensed provider.
Deductible means the portion of the healthcare expense that must be paid by the member before the
benefits of this plan are applied.
Dental emergency means the sudden and unexpected onset of a condition, or exacerbation of an
existing condition, requiring necessary care to control pain, swelling or bleeding in or around the teeth
and gums. Such emergency care must be provided within 48 hours following the onset of the
emergency and includes treatment for acute infection, pain, swelling, bleeding, or injury to natural teeth
and oral structures. The emergency care does not include follow-up care such as, but not limited to,
crowns, root canal therapy, or prosthetic benefits.
Dentist means a person acting within the scope of their license, holding the degree of Doctor of
Medicine (M.D.), Doctor of Dental Surgery (D.D.S.), or Doctor of Dental Medicine (D.M.D.), and who is
legally entitled to practice dentistry in all its branches under the laws of the state or jurisdiction where
the services are rendered.
Durable medical equipment means equipment that can withstand repeated use; is primarily and
customarily used to serve a medical purpose rather than convenience or comfort; is generally not useful
to a person in the absence of an illness or injury; is appropriate for use in the home; and is prescribed
by a physician. Examples of durable medical equipment include but are not limited to hospital beds,
wheelchairs, crutches, canes, walkers, nebulizers, commodes, suction machines, traction equipment,
respirators, TENS units, and hearing aids.
Durable medical equipment supplier means a PacifcSource contracted provider or a provider that
satisfies the criteria in the Medicare Qualify Standards for Suppliers of Durable Medical Equipment,
Prosthetics, Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description.
Elective surgery or procedure refers to a surgery or procedure for a condition that does not require
immediate attention and for which a delay would not have a substantial likelihood of adversely affecting
the health of the patient.
Eligible dental provider means a physician, dentist, oral surgeon, endodontist, orthodontist,
periodontist, or pedodontist. Eligible provider may also include a denturist or dental hygienist to the
extent that he/she operates within the scope of their license.
Emergency medical condition means a medical condition:
• That manifests itself by acute symptoms of sufficient severity, including severe pain that a prudent
layperson possessing an average knowledge of health and medicine would reasonably expect that
failure to receive immediate medical attention would:
- Place the health of a person, or an unborn child in the case of a pregnant woman, in serious
jeopardy;
- Result in serious impairment to bodily functions; or
- Result in serious dysfunction of any bodily organ or part; or
• With respect to a pregnant woman who is having contractions, for which there is inadequate time to
affect a safe transfer to another hospital before delivery or for which a transfer may pose a threat to
the health or safety of the woman or the unborn child.
Emergency medical screening exam means the medical history, examination, ancillary tests, and
medical determinations required to ascertain the nature and extent of an emergency medical condition.
SingleSource Self-Insured 74
Exhibit 'A'
Emergency services means, with respect to an emergency medical condition:
• An emergency medical screening exam that is within the capability of the emergency department of
a hospital, including ancillary services routinely available to the emergency department to evaluate
such emergency medical condition, and
• Such further medical examination and treatment as are required under 42 U.S.C. 1395dd to
stabilize the patient to the extent the examination and treatment are within the capability of the staff
and facilities available at a hospital.
Employee means any individual employed by a Plan Sponsor.
Endorsement is a written attachment that alters and supersedes any of the terms or conditions set
forth in this contract.
Enrollee means an employee, dependent of the employee, or individual otherwise eligible and enrolled
for coverage under this plan. In this policy, enrollee is referred to as subscriber or member.
Essential health benefits are services defined as such by the Secretary of the U.S. Department of
Health and Human Services. Essential health benefits fall into the following categories:
• Ambulatory patient services,
• Emergency services;
• Hospitalization;
• Maternity and newborn care;
• Mental health and substance use disorder services, including behavioral health treatment;
• Prescription drugs;
• Rehabilitative and habilitative services and devices;
• Laboratory services;
• Preventive and wellness services and chronic disease management; and
• Pediatric services, including oral and vision care.
Exclusion period means a period during which specified conditions, treatments or services are
excluded from coverage.
Experimental or investigational procedures means services, supplies, protocols, procedures,
devices, chemotherapy, drugs or medicines, or the use thereof, that are experimental or investigational
for the diagnosis and treatment of illness or injury.
Experimental or investigational services and supplies include, but are not limited to, services,
supplies, procedures, devices, chemotherapy, drugs or medicines, or the use thereof, which at the
time they are rendered and for the purpose and in the manner they are being used:
- Have not yet received full U.S. government agency required approval (e.g., FDA) for other
than experimental, investigational, or clinical testing;
- Are not of generally accepted medical practice in the state of Oregon or as determined by
PacificSource in consultation with medical advisors, medical associations, and/or technology
resources;
- Are not approved for reimbursement by the Centers for Medicare and Medicaid Services,
Are furnished in connection with medical or other research; or
- Are considered by any governmental agency or subdivision to be experimental or
investigational, not considered reasonable and necessary, or any similar finding.
• When making decisions about whether treatments are investigational or experimental,
PacificSource relies on the above resources as well as:
- Expert opinions of specialists and other medical authorities;
Published articles in peer-reviewed medical literature;
- External agencies whose role is the evaluation of new technologies and drugs; and
- External review by an independent review organization.
SingleSource Self-Insured 75
Exhibit'A'
• The following will be considered in making the determination whether the service is in an
experimental and/or investigational status:
Whether there is sufficient evidence to permit conclusions concerning the effect of the
services on health outcomes;
- Whether the scientific evidence demonstrates that the services improve health outcomes as
much or more than established alternatives;
Whether the scientific evidence demonstrates that the services' beneficial effects outweigh
any harmful effects, and
Whether any improved health outcomes from the services are attainable outside an
investigational setting.
Formulary is a list of approved brand name medications used to treat various medical conditions. The
formulary list is developed by the pharmacy benefits management company and PacificSource.
Generic drugs are drugs that, under federal law, require a prescription by a licensed physician (M.D. or
D.O.) or other licensed medical provider and are not a brand name medication. By law, generic drugs
must have the same active ingredients as the brand name medication and are subject to the same
standards of their brand name counterpart.
Grievance means:
• A request submitted by a member or an authorized representative of a member;
In writing, for an internal appeal or an external review; or
In writing or orally, for an expedited internal review or an expedited external review; or
• A written complaint submitted by a member or an authorized representative of a member regarding:
- The availability, delivery, or quality of a healthcare service;
Claims payment, handling, or reimbursement for healthcare services and, unless the member
has not submitted a request for an internal appeal, the complaint is not disputing an adverse
benefit determination; or
- Matters pertaining to the contractual relationship between a member and PacificSource.
Health care provider means a physician, practitioner, nurse, hospital or specialized treatment facility
as defined in this document.
Health benefit plan means any hospital expense, medical expense, or hospital or medical expense
policy or certificate, healthcare contractor or health maintenance organization subscriber contract, or
any plan provided by a multiple employer welfare arrangement or by another benefit arrangement
defined in the federal Employee Retirement Income Security Act of 1974, as amended, to the extent
that plan is subject to state regulation.
Hearing aids mean any nondisposable, wearable instrument or device designed to aid or compensate
for impaired human hearing and any necessary ear mold, part, attachments or accessory for the
instrument or device, except batteries and cords. Hearing aids include any amplifying device that does
not produce as its output an electrical signal that directly stimulates the auditory nerve. For the purpose
of this definition, such amplifying devices include air conduction and bone conduction devices, as well
as those that provide vibratory input to the middle ear.
Homebound means the ability to leave home only with great difficulty with absences infrequently and
of short duration. Infants and toddlers will not be considered homebound without medical
documentation that clearly establishes the need for home skilled care. Lack of transportation is not
considered sufficient medical criterion for establishing that a person is homebound.
Hospital means an institution licensed as a'general hospital' or 'intermediate general hospital' by the
appropriate state agency in the state in which it is located.
Illness includes a physical or mental condition that results in a covered expense. Physical illness is a
disease or bodily disorder. Mental illness is a psychological disorder that results in pain or distress and
substantial impairment of basic or normal functioning.
Incurred expense means charges of a healthcare provider for services or supplies for which a member
becomes obligated to pay. The expense of a service is incurred on the day the service is rendered, and
the expense of a supply is incurred on the day the supply is delivered.
SingleSource Self-Insured 76
Exhibit 'A'
Initial enrollment period means a period of 31 days following the date an individual is first eligible to
enroll.
Injury means bodily trauma or damage that is independent of disease or infirmity. The damage must be
caused solely by external and accidental means and does not include muscular strain sustained while
performing a physical activity.
Inquiry means a written request for information or clarification about any subject matter related to the
member's health benefit plan.
Internal appeal means a review by PacificSource or your Plan Sponsor of an adverse benefit
determination made by PacificSource.
Leave of absence is a period of time off work granted to an employee by the Plan Sponsor at the
employee's request and during which the employee is still considered to be employed and is carried on
the employment records of the Plan Sponsor. A leave can be granted for any reason acceptable to the
Plan Sponsor, including disability and pregnancy.
Lifetime means the period of time a member is enrolled in this plan or any other Plan Sponsored by the
Plan Sponsor.
Mastectomy is the surgical removal of all or part of a breast or a breast tumor suspected to be
malignant.
Medically necessary means those services and supplies that are required for diagnosis or treatment of
illness or injury and that are:
• Consistent with the symptoms or diagnosis and treatment of the condition;
• Consistent with generally accepted standards of good medical practice in the state of Oregon, or
expert consensus physician opinion published in peer-reviewed medical literature, or the results of
clinical outcome trials published in peer-reviewed medical literature;
• As likely to produce a significant positive outcome as, and no more likely to produce a negative
outcome than, any other service or supply, both as to the disease or injury involved and the
patient's overall health condition;
• Not for the convenience of the member or a provider of services or supplies;
• The least costly of the alternative services or supplies that can be safely provided. When
specifically applied to a hospital inpatient, it further means that the services or supplies cannot be
safely provided in other than a hospital inpatient setting without adversely affecting the patient's
condition or the quality of medical care rendered.
Services and supplies intended to diagnose or screen for a medical condition in the absence of signs or
symptoms, or of abnormalities on prior testing, including exposure to infectious or toxic materials or
family history of genetic disease, are not considered medically necessary under this definition (see
General Exclusions - Screening tests).
Medical supplies means items of a disposable nature that may be essential to effectively carry out the
care a physician has ordered for the treatment or diagnosis of an illness or injury. Examples of medical
supplies include but are not limited to syringes and needles, splints and slings, ostomy supplies, sterile
dressings, elastic stockings, enteral foods, drugs or biologicals that must be put directly into the
equipment in order to achieve the therapeutic benefit of the durable medical equipment or to assure the
proper functioning of this equipment (e.g. Albuterol for use in a nebulizer).
Member means an individual insured through the Plan Sponsor.
Mental and/or chemical healthcare facility means a corporate or governmental entity or other
provider of services for the care and treatment of chemical dependency and/or mental or nervous
conditions which is licensed or accredited by the Joint Commission on Accreditation of Hospitals or the
Commission on Accreditation of Rehabilitation Facilities for the level of care which the facility provides.
Mental and/or chemical healthcare program means a particular type or level of service that is
organizationally distinct within a mental and/or chemical healthcare facility.
Mental and/or chemical healthcare provider means a person that has met the credentialing
requirements of PacificSource, is otherwise eligible to receive reimbursement under the policy and is:
• A healthcare facility where appropriately licensed or accredited by the Commission on Accreditation
of Hospitals or the Commission on Accreditation of Rehabilitation Facilities;
• A residential program or facility;
SingleSource Self-Insured 77
Exhibit 'A'
• A day or partial hospitalization program;
• An outpatient service; or
• An individual behavioral health or medical professional authorized for reimbursement under Oregon
law.
Mental or nervous conditions means all disorders listed in the'Diagnostic and Statistical Manual of
Mental Disorders, DSM-IV-TR, Fourth Edition' except for:
• Mental Retardation (diagnostic codes 317, 318.0, 318.1, 318.2, 319);
• Learning Disorders (diagnostic codes 315.00, 315.1, 315.2, 315.9);
• Paraphilias (diagnostic codes 302.4, 302.81, 302.89, 302.2, 302.83, 302.84, 302.82, 302.9); and
• Gender Identity Disorders in Adults (diagnostic codes 302.85, 302.6, 302.9 - this exception does
not extend to children and adolescents 18 years of age or younger); and
• 'V' codes (diagnostic codes V15.81 through V71.09 - this exception does not extend to children five
years of age or younger for diagnostic codes V61.20, V61.21, and V62.82).
Network not available means a member does not have reasonable geographic access to a
PacificSource participating provider for a medical service or supply.
Non-participating provider is a provider of covered medical services or supplies that does not directly
or indirectly hold a provider contract or agreement with PacificSource.
Non-preferred drugs are covered brand name medications not on the Preferred Drug List.
Orthotic devices means rigid or semirigid devices supporting a weak or deformed leg, foot, arm, hand,
back or neck or restricting or eliminating motion in a diseased or injured leg, foot, arm, hand, back or
neck. Benefits for orthotic devices include orthopedic appliances or apparatus used to support, align,
prevent, or correct deformities or to improve the function of movable parts of the body. An orthotic
device differs from a prosthetic in that, rather than replacing a body part, it supports and/or rehabilitates
existing body parts. Orthotic devices are usually customized for an individual's use and are not
appropriate for anyone else. Examples of orthotic devices include but are not limited to Ankle Foot
Orthosis (AFO), Knee Ankle Foot Orthosis (KAFO), Lumbosacral Orthosis (LSO), and foot orthotics.
PacificSource refers to PacificSource Health Plans. PacificSource is the claims administrator of the
Plan Sponsor's medical, vision and pharmacy coverage. References to PacificSource as paying claims
or issuing benefits means that PacificSource processes a claim in accordance with the provisions of the
Plan Sponsor's plans.
Participating provider means a physician, healthcare professional, hospital, medical facility, or
supplier of medical supplies that directly or indirectly holds a provider contract or agreement with the
plan.
Periapical x-ray is an x-ray of the area encompassing or surrounding the tip of the root of a tooth.
Periodontal maintenance is a periodontal procedure for patients who have previously been treated for
periodontal disease. In addition to cleaning the visible surfaces of the teeth (as in prophylaxis) surfaces
below the gum-line are also cleaned. This is a more comprehensive service than a regular cleaning
(prophylaxis).
Periodontal scaling and root planing means the removal of plaque and calculus deposits from the
root surface under the gum line.
Physical/occupational therapy is comprised of the services provided by (or under the direction and
supervision of) a licensed physical or occupational therapist. Physical/occupational therapy includes
emphasis on examination, evaluation, and intervention to alleviate impairment and functional limitation
and to prevent further impairment or disability.
Physician means a state-licensed Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.).
Physician assistant is a person who is licensed by an appropriate state agency as a physician
assistant.
Plan means the City of Ashland Employee Benefits Plan, and all documents, including any insurance
contracts, administrative service agreements, Summary Plan Descriptions and any related terms and
conditions associated with the Plan.
SingleSource Self-Insured 78
Exhibit 'A'
Plan Administrator means the Risk Services Division of the City of Ashland, which has responsibility
for the management of the plan.
Plan Sponsor ('the Plan Sponsoe or'your Plan Sponsor), means the City of Ashland. The City of
Ashland is the fiduciary of the plan, and exercises all discretionary authority and control over the
administration of the plan and the management and disposition of plan assets. The Plan Sponsor shall
have the sole discretionary authority to determine eligibility for plan benefits or to construe the terms of
the plan, and benefits under the plan will be paid only if the Plan Sponsor decides, in its discretion, that
the memberor beneficiary is entitled to such benefits. The Plan Sponsor has the right to amend,
modify, or terminate the plan in any manner, at any time, regardless of the health status of any plan
member or beneficiary.
Plan Year means the twelve-month period of time for the City of Ashland beginning January 1, and
ending December 31.
Practitioner means Doctor or Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery
(D.D.S.), Doctor of Dental Medicine (D.M.D.), Doctor of Podiatry Medicine (D.P.M.), Doctor of
Chiropractic (D.C.), Doctor of Optometry (O.D.), Licensed Nurse Practitioner (including Certified Nurse
Midwife (C.N.M.) and Certified Registered Nurse Anesthetist (C.R.N.A.)), Registered Physical Therapist
(R.P.T.), Speech Therapist, Occupational Therapist, Psychologist (Ph.D.), Licensed Clinical Social
Worker (L.C.S.W.), Licensed Professional Counselor (L.P.C.), Licensed Marriage and Family Therapist
(LMFT), Licensed Psychologist Associate (LPA), Physician Assistant (PA), Audiologist, Acupuncturist,
Naturopathic Physician, and Licensed Massage Therapist.
Pre-existing condition means a condition (physical or mental) for which medical advice, diagnosis,
care, or treatment was recommended by or received from a licensed provider within the six-month
period ending on the enrollment date. For the purpose of this definition, the enrollment date of a
member is the earlier of the effective date of coverage or the first day of any required group eligibility
waiting period, and the enrollment date of a late enrollee is the effective date of coverage. Pregnancy
does not constitute a pre-existing condition, nor does genetic information without a diagnosis of a
condition related to such information.
Preferred is a list of approved brand name medications used to treat various medical conditions. The
Preferred Drug List is developed by the pharmacy benefits management company and PacificSource.
Prescription drugs are drugs that, under federal law, require a prescription by a licensed physician
(M.D. or D.O.) or other licensed medical provider.
Prophylaxis is a cleaning and polishing of all teeth.
Prosthetic devices (excluding dental) means artificial limb devices or appliances designed to replace
in whole or in part an arm or a leg. Benefits for prosthetic devices include coverage of devices that
replace all or part of an internal or external body organ, or replace all or part of the function of a
permanently inoperative or malfunctioning internal or external organ, and are furnished on a physician's
order. Examples of prosthetic devices include but are not limited to artificial limbs, cardiac pacemakers,
prosthetic lenses, breast prosthesis (including mastectomy bras), and maxillofacial devices.
Pulpotomy is the removal of a portion of the pulp, including the diseased aspect, with the intent of
maintaining the vitality of the remaining pulpal tissue by means of a therapeutic dressing.
Qualified domestic partner means a registered domestic partner or unregistered same gender
domestic partner with an Affidavit of Domestic Partnership, supplied by the Plan Sponsor.
Restoration is the treatment that repairs a broken or decayed tooth. Restorations include, but are not
limited to, fillings and crowns.
Routine costs of care means medically necessary conventional care, items, or services covered by
the health benefit plan if typically provided absent a clinical trial. Routine costs of care do not include:
• The drug, device, or service being tested in the clinical trial unless the drug, device, or service
would be covered for that indication by the policy if provided outside of a clinical trial;
• Items or services required solely for the provisions of the drug, device, or service being tested in
the clinical trial;
• Items or services required solely for the clinically appropriate monitoring of the drug, device, or
service being tested in the clinical trial;
• Items of services required solely for the prevention, diagnosis, or treatment of complications arising
from the provision of the drug, device, or service being tested in the clinical trial;
SingleSource Self-Insured 79
Exhibit'A'
• Items or services that are provided solely to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient,
• Items or services customarily provided by a clinical trial sponsor free of charge to any participant in
the clinical trial; or
• Items or services that are not covered by the policy if provided outside of the clinical trial.
Seasonal employee is an employee who is hired with the agreement that their employment will end
after a predetermined period of time.
Skilled nursing facility convalescent home means an institution that provides skilled nursing care
under the supervision of a physician, provides 24-hour nursing service by or under the supervision of a
registered nurse (R.N.), and maintains a daily record of each patient. Skilled nursing facilities must be
licensed by an appropriate state agency and approved for payment of Medicare benefits to be eligible
for reimbursement.
Specialized treatment facility means a facility that provides specialized short-term or long-term care.
The term specialized treatment facility includes ambulatory surgical centers, birthing centers, chemical
dependency/substance abuse day treatment facilities, hospice facilities, inpatient rehabilitation facilities,
mental and/or chemical healthcare facilities, organ transplant facilities, psychiatric day treatment
facilities, residential treatment facilities, skilled nursing facilities, substance abuse treatment facilities,
and urgent care treatment facilities.
Specialty drugs are high dollar oral, injectable, infused or inhaled biotech medications prescribed for
the treatment of chronic and/or genetic disorders with complex care issues that have to be managed.
The major conditions these drugs treat include but are not limited to: cancer, HIV/AIDS, hemophilia,
hepatitis C, multiple sclerosis, Crohn's disease, rheumatoid arthritis, and growth hormone deficiency.
Specialty pharmacies specialize in the distribution of specialty drugs and providing pharmacy care
management services designed to assist patients in effectively managing their condition.
Stabilize means to provide medical treatment as necessary to ensure that, within reasonable medical
probability, no material deterioration of an emergency medical condition is likely to occur during or to
result from the transfer of the patient from a facility; and with respect to a pregnant woman who is in
active labor, to perform the delivery, including the delivery of the placenta.
Subscriber means an employee or former employee insured under the Plan Sponsor's health policy
through PacificSource. When a family unit that does not include an employee or former employee is
insured under a policy, the oldest family member is referred to as the subscriber.
Surgical procedure means any of the following operative procedures:
• Procedures accomplished by cutting or incision
• Suturing of wounds
• Treatment of fractures, dislocations, and burns
• Manipulations under general anesthesia
• Visual examination of the hollow organs of the body including biopsy, or removal of tumors or
foreign body
• Procedures accomplished by the use of cannulas, needling, or endoscopic instruments
• Destruction of tissue by thermal, chemical, electrical, laser, or ultrasound
Telemedical means medical services delivered through a two-way video communication that allows a
provider to interact with a patient who is at a different physical location than the provider.
Temporomandibular Joint Disorder (TMJ) means any dysfunction or disorder of the jaw joint
resulting in pain and impairment of the jaw.
Third Party Administrator is an administrator hired by the Plan Sponsorto perform claims processing
and other specified administrative services in relation to the plan. The third party administrator is not an
insurer of health benefits under this plan, is not a fiduciary of the plan, and does not exercise any of the
discretionary authority and responsibility granted to the Plan Sponsor. The third party administrator is
not responsible for plan financing and does not guarantee the availability of benefits under this plan.
The third party administrator is PacificSource Health Plans
SingleSource Self-Insured 80
Exhibit'A'
Tobacco use cessation program means a program recommended by a physician that follows the
United States Public Health Services guidelines for tobacco use cessation. Tobacco use cessation
program includes education and medical treatment components designed to assist a person in ceasing
the use of tobacco products.
Unregistered domestic partner means an individual of the same-gender who is joined in a domestic
partnership with the subscriber and meets the following criteria:
• Is at least 18 years of age;
• Not related to the policyholder by blood closer than would bar marriage in Oregon or the state
where they have permanent residence and are domiciled;
• Shares jointly the same permanent residence with the policyholder for at least six months
immediately preceding the date of application to enroll and intent to continue to do so indefinitely;
• Has joint financial accounts with the policyholder and has agreed to be jointly responsible with the
policyholder for each others' common welfare, including basic living expenses,
• Has an exclusive domestic partnership with the policyholder and has no other domestic partner;
• Does not have a legally binding marriage nor has had another domestic partner within the previous
six months;
• Was mentally competent to consent to contract when the domestic partnership began and remains
mentally competent.
Urgent care treatment facility means a healthcare facility whose primary purpose is the provision of
immediate, short-term medical care for minor, but urgent, medical conditions.
Waiting period means the period of time before coverage becomes effective for a memberwho is
otherwise eligible to enroll in the plan.
Women's healthcare provider means an obstetrician, gynecologist, physician assistant or nurse
practitioner specializing in women's health, or certified nurse midwife practicing within the applicable
scope of practice.
RIGHTS OF PLAN MEMBERS
MEDICAID AND CHIP STATE CONTACT INFORMATION
If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from
your Plan Sponsor, your State may have a premium assistance program that can help pay for
coverage. These States use funds from their Medicaid or CHIP programs to help people who are
eligible for these programs, but also have access to health insurance through their Plan Sponsor. If you
or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium
assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below,
you can contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of
your dependents might be eligible for either of these programs, you can contact your State Medicaid or
CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you
qualify, you can ask the State if it has a program that might help you pay the premiums for a Plan
Sponsor-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid
or CHIP, as well as eligible under your Plan Sponsor plan, your Plan Sponsor must permit you to enroll
in your Plan Sponsor plan if you are not already enrolled. This is called a 'special enrollment'
opportunity, and you must request coverage within 60 days of being determined eligible for
premium assistance. If you have questions about enrolling in your Plan Sponsor plan, you can contact
the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA
(3272).
If you live in one of the following States, you may be eligible for assistance paying your Plan Sponsor
health plan premiums. The following list of States is current as of July 31, 2012. You should contact
your State for further information on eligibility -
SingleSource Self-Insured 81
Exhibit'A'
ALABAMA - Medicaid COLORADO - Medicaid
Website: http://www.medicaid.alabama.gov Medicaid Website: http://www.colorado.gov/
Phone: 1-855-692-5447 Medicaid Phone (In state): 1-800-866-3513
ALASKA - Medicaid Medicaid Phone (Out of state): 1-800-221-3943
Website:
hftp://health.hss.state.ak.us/dpa/programs/mediGaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA - CHIP FLORIDA - Medicaid
Website: http://www.azahcccs.gov/applicants Website: https://www.flmedicaidtpirecovery.com/
Phone (Outside of Maricopa County): 1-877-764-5437 Phone: 1-877-357-3268
Phone (Maricopa County): 602-417-5437 GEORGIA - Medicaid
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150
IDAHO - Medicaid and CHIP MONTANA - Medicaid
Medicaid Website: Website:
www.arcesstohealthinsurance.idaho.gov http://medicaidprovider.hhs.mt.gov/clientpages/
Medicaid Phone: 1-800-926-2588 clientindex.shtml
CHIP Website: www.medicaid.idaho.gov Phone: 1-800-694-3084
CHIP Phone: 1-800-926-2588
INDIANA - Medicaid NEBRASKA -Medicaid
Website: http://www.in.gov/fssa Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-889-9949 Phone: 1-800-383-4278
IOWA - Medicaid NEVADA - Medicaid
Website: www.dhs.state.ia.us/hipp/ Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562 Medicaid Phone: 1-800-992-0900
KANSAS - Medicaid
Website: http:/twww.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY - Medicaid NEW HAMPSHIRE - Medicaid
Website: http://chfs.ky.gov/dms/default.htm Website:
Phone: 1-800-635-2570 http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA - Medicaid NEW JERSEY - Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov Medicaid Website:
Phone: 1-888-695-2447 http:/Awm.state.nj.us/humanservices/
MAINE-Medicaid dmahs/clients/medicaid/
Website: http:/twww.maine.gov/dhhs/ofi/public- Medicaid Phone: 1-800-356-1561
assistance/index.html CHIP Website:
Phone: 1-800-977-6740 http:/Avww.njfamilycare.org/index.html
TTY 1-800-977-6741 CHIP Phone: 1-800-701-0710
MASSACHUSETTS - Medicaid and CHIP NEW YORK - Medicaid
Website: http://www.mass.gov/MassHealth Website:
Phone: 1-800-462-1120 http:/hvww.nyhealth.gov/health-care/medicaid/
Phone: 1-800-541-2831
MINNESOTA -Medicaid NORTH CAROLINA - Medicaid
Website: http://www.dhs.state.mn.us/ Website: http://www.ncdhhs.gov/dma
Click on Health Care, then Medical Assistance Phone: 919-855-4100
Phone: 1-800-657-3629
MISSOURI - Medicaid NORTH DAKOTA -Medicaid
Website: Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.ht http://www.nd.gov/dhs/services/medicalservimedicai
m d/ >
Phone: 5L3-751-2005 Phone: 1-800-755-2604
OKLAHOMA - Medicaid and CHIP UTAH - Medicaid and CHIP
Website: http://www.insureoklahoma.org Website: http://health.utah.gov/upp
Phone: 1-888-365-3742 Phone: 1-866-435-7414
SingleSource Self-Insured 82
Exhibit'A'
OREGON - Medicaid and CHIP VERMONT- Medicaid
Website: http://www.oregonhealthykids.gov Website: http://www.greenmountaincare.org/
http://www.hijossaludablesoregon.gov Phone: 1-80G-250-8427
Phone: 1-877-314-5678
PENNSYLVANIA - Medicaid VIRGINIA - Medicaid and CHIP -
Website: http:/Avww.dpw.state.pa.us/hipp Medicaid Website:
Phone: 1-800-692-7462 http://www.dmas.virginia.gov/rcp-HIPP.htm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
RHODE ISLAND - Medicaid WASHINGTON - Medicaid
Website: www.ohhs.ri.gov Website:
Phone: 401-462-5300 http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone: 1-800-562-3022 ext. 15473
SOUTH CAROLINA - Medicaid WEST VIRGINIA - Medicaid
Website: http://www.scdhhs.gov Website: www.dhhr.wv.gov/bms/
Phone: 1-888-549-0820 Phone: 1-877-598-5820, HMS Third Party Liability
SOUTH DAKOTA - Medicaid WISCONSIN - Medicaid
Website: http://dss.sd.gov Website: http://www.badgercareplus.org/pubs/p-
Phone: 1-888-828-0059 10095.htm
Phone: 1-800-362-3002
TEXAS - Medicaid WYOMING - Medicaid
Website: https:/Avww.gethipptexas.com/ Website:
Phone: 1-800-440-0493 http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531
To see if any more States have added a premium assistance program since July 31, 2012, or for more
information on special enrollment rights, you can contact either:
U.S. Department of Labor U.S. Department of Health & Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cros.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565
OMB Control Number 1210-0137 (expires 09130/2013)
SingleSource Self-Insured 83
Exhibit 'A'
SingleSource Self-Insured 84
Exhibit 'A'
PLAN INFORMATION
Name and Address of the Plan Sponsor
City of Ashland
20 East Main
Ashland, OR 97520
(541) 488-6002
Name and Address of the Designated Agent for Service of Legal Process
Dave Kanner, City Administrator
20 East Main
Ashland, OR 97520
541-488-6002
Name and Address of the Third Party Administrator
PacificSource Health Plans
PO Box 7068
Springfield, OR 97475-0068
(888) 977-9299
Fax: (541) 684-5264
Internal Revenue Service and Plan Identification Number
The corporate tax identification number assigned by the Internal Revenue Service is
936002117.
Plan Year
The plan year is the 12-month period of time beginning January 1 and ending December 31.
Method of Funding Benefits
Health benefits are self-insured from the general assets and or trust funds of the Plan Sponsor
and are not guaranteed under an insurance policy or contract. The Plan Sponsor may purchase
excess risk insurance coverage which is intended to reimburse the Plan Sponsor for certain
losses incurred and paid under the plan by the Plan Sponsor. Such excess risk coverage, if
any, is not part of the plan. The cost of the plan is paid with contributions by the Plan Sponsor
and participating employees. The Plan Sponsor determines the amount of contributions to the
plan, based on estimates of claims and administration costs.
Payments out of the plan to health care providers on behalf of the covered person will be based
on the provisions of the plan.
SingleSource Self-Insured 85
Exhibit'A'
SingleSource Self-Insured 86
Exhibit'A'
SIGNATURE PAGE
The effective date of the Preferred 90+200 VAR GF 0812 is July 1, 2013.
It is agreed by the City of Ashland that the provisions of this document are correct and will be the
basis for the administration of the Preferred 90+200 VAR GF 0812.
Dated this day of
ay
Title
SingleSource Self-Insured 87
Exhibit,'A'
y
SingleSource Self-Insured 88
Exhibit'B'
CITY OF
ASHLAND
City of Ashland - Parks
Group No.: G0032482
Preferred 90+200 VAR GF 0812
Effective: July 1, 2013
Third Party Administrative Services Provided By:
PaciticSource
HEALTH PLANS
SPD 0713_City of Ashland-Parks SingleSource Self-Insured
Exhibit'B'
i
SingleSource Self-Insured 2
Exhibit'B'
INTRODUCTION
Welcome to your City of Ashland (also referred to as'the employer or'employer) group health plan. Your
employer offers this coverage to help you and your family members stay well, and to protect you in case
of illness or injury. Your plan includes a wide range of benefits and services, and PacificSource hopes
you will take the time to become familiar with them.
Your employer, who is also the Plan Sponsor, has prepared this document to help you understand how
your plan works and how to use it. This document summarizes the benefits provided under the Preferred
90+200 VAR GF 0812 Plan (referred to as 'the plan' or 'this plan' throughout this document). Please read
it carefully and thoroughly. Your benefits are affected by certain limitations and conditions, which require
you to be a wise consumer of health services and to use only those services you need. Also, benefits are
not provided for certain kinds of treatments or services, even if your health care provider recommends
them.
The plan is a self-insured medical plan intended to meet the requirements of Sections 105(b), 105(h), and
106 of the Internal Revenue Code so that the portion of the cost of coverage paid by your Plan Sponsor,
and any benefits received by you through this plan, are not taxable income to you. Your specific tax
treatment will depend on your personal circumstances; the plan does not guarantee any particular tax
treatment. You are solely responsible for any and all federal, state, and local taxes attributable to your
participation in this plan, and the plan expressly disclaims any liability for such taxes.
The plan is 'self-insured,' which means benefits are paid from your employers general assets and or trust
funds and are not guaranteed by an insurance company. The Plan Sponsor has contracted with a Third
PartyAdministmtorto perform certain administrative services related to this plan.
PacificSource Health Plans is the Third Party Administrator and provides administrative services for this
plan on behalf of the Plan Sponsor. If anything is unclear to you, PacificSource's staff is available to
answer your questions. Please give them a call or visit them on the Internet at PacificSource.com.
PacificSource looks forward to serving you and your family.
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extensi6n 1009
cs@pacifcsource.com
This document serves as the written Plan document and Summary Plan Description (SPD). It is very
important that you review the entire document carefully to confirm a complete understanding of the
benefits available, as well as your responsibility, under the plan.
This document is written in simple, easy-to-understand language. Technical terms are printed in italics
and defined in the Plan Terms and Definitions section. This document explains the services covered by
the plan; the benefit summaries tell you how much this plan pays toward expenses and amounts for
which you are responsible.
As used in this document, the word 'year' refers to the benefit year, which is the 12-month period
beginning January 1 and ending December 31. The word lifetime as used in this document refers to the
period of time you or your eligible dependents participate in this plan or any other Plan Sponsored by the
Plan Sponsor.
Any amount you or your eligible dependents have accumulated toward the benefit maximum amounts,
deductible, or out-of-pocket maximum of any immediately prior Plan Sponsored by the Plan Sponsor will
be counted toward the benefit maximum amounts of this plan.
The Plan Sponsorreserves the right to amend, modify, or terminate this plan in any manner, at any time,
which may result in termination or modification of your coverage. If this plan is terminated, any plan
assets will be used to pay for eligible expenses incurred prior to the plan's termination, and such
expenses will be paid as provided under the terms of this plan prior to termination. If there is any conflict
between this document and the underlying plan document(s), the plan document(s) control.
SingleSource Self-Insured 3
Exhibit'B'
SingleSource Self-Insured 4
Exhibit 'B'
CONTENTS
MEDICAL BENEFIT SUMMARY 3
PRESCRIPTION BENEFIT SUMMARY 5
CHIROPRACTIC CARE BENEFIT SUMMARY 9
ADDITIONAL ACCIDENT BENEFIT SUMMARY .........................................................11
VISION BENEFIT SUMMARY ......................................................................................13
DENTAL BENEFIT SUMMARY ....................................................................................15
ORTHODONTIA BENEFITS .........................................................................................17
USING THE PROVIDER NETWORK ............................................................................19
Preferred Provider Organization (PPO) .................................................................................................19
What is a PPO .......................................................................................................................................19
Who is Your PPO ...................................................................................................................................19
About Your PPO ....................................................................................................................................19
Nan-PPO Providers ...............................................................................................................................20
Example of Provider Payment ...............................................................................................................20
Allowable Amount 20
NETWORK NOT AVAILABLE BENEFITS 20
COVERAGE WHILE TRAVELING 20
Nonemergency Care While Traveling ....................................................................................................21
Emergency Services While Traveling ....................................................................................................21
FINDING PARTICIPATING PROVIDER INFORMATION 21
TERMINATION OF PROVIDER CONTRACTS 21
BECOMING ELIBIGLE .................................................................................................22
Who Pays for Your Benefits ...................................................................................................................22
Who is Eligible .......................................................................................................................................22
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD 23
Newborns 23
Adopted Children 23
Family Members Acquired by Marriage .................................................................................................23
Family Members Acquired by Domestic Partnership .............................................................................23
Family Members Placed in Your Guardianship .....................................................................................24
Qualified Medical Child Support Orders ................................................................................................24
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD 24
Returning to Work after a Layoff ............................................................................................................24
Returning to Work after a Leave of Absence .........................................................................................24
Returning to Work after Family Medical Leave ......................................................................................24
Special Enrollment Periods ....................................................................................................................25
Dental Enrollment ..................................................................................................................................25
Late Enrollment ......................................................................................................................................25
Member ID Card ....................................................................................................................................26
PLAN SELECTION PERIOD 26
TERMINATING COVERAGE 26
Divorced Spouses ..................................................................................................................................26
Dependent Children ...............................................................................................................................26
Dissolution of Domestic Partnership ......................................................................................................26
SingleSource Self-Insured 5
Exhibit'B'
Certificates of Creditable Coverage .......................................................................................................27
CONTINUATION OF INSURANCE 27
USERRA CONTINUATION 27
Surviving or Divorced Spouses and Qualified Domestic Partners .........................................................28
COBRA CONTINUATION 28
COBRA Eligibility 28
When Continuation Coverage Ends ......................................................................................................28
Type of Coverage 29
Your Responsibilities and Deadlines .....................................................................................................29
Continuation Premium ...........................................................................................................................29
Keep Your Plan Informed of Address Changes .....................................................................................29
CONTINUATION WHEN YOU RETIRE 29
WORK STOPPAGE ......................................................................................................30
Labor Unions ..........................................................................................................................................30
COVERED EXPENSES 30
Medical Necessity ..................................................................................................................................30
Healthcare Providers .............................................................................................................................31
Your Annual Out-of-Pocket Limit 31
MEDICAL BENEFITS 31
About Your Medical Benefits .................................................................................................................31
PLAN BENEFITS 33
PREVENTIVE CARE SERVICES 33
PROFESSIONAL SERVICES 34
HOSPITAL AND SKILLED NURSING FACILITY SERVICES 36
OUTPATIENT SERVICES 36
EMERGENCY SERVICES ............................................................................................37
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES 38
Mental Health and Chemical Dependency Services .............................................................................38
Medical Necessity and Appropriateness of Treatment ..........................................................................39
HOME HEALTH AND HOSPICE SERVICES 39
DURABLE MEDICAL EQUIPMENT .............................................................................40
TRANSPLANT SERVICES ...........................................................................................41
Payment of Transplant Benefits .............................................................................................................42
OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS .............................42
BENEFIT LIMITATIONS AND EXCLUSIONS ..............................................................45
Least Costly Setting for Services ...........................................................................................................45
EXCLUDED SERVICES 45
A Note About Optional Benefits .............................................................................................................45
Experimental or Investigational Treatment ............................................................................................49
EXCLUSION PERIODS ................................................................................................52
Exclusion Period for Transplant Benefits ...............................................................................................52
SingleSource Self-Insured 6
Exhibit 'B'
CREDIT FOR PRIOR COVERAGE 52
Evidence of Prior Creditable Coverage .................................................................................................52
HEALTH CARE MANAGEMENT AND PREAUTHORIZATION 52
What is Health Care Management .........................................................................................................52
Case Management .................................................................................................................................53
Individual Benefits management ............................................................................................................54
HOW TO USE YOUR DENTAL PLAN 54
DENTAL PLAN BENEFITS 54
COVERED DENTAL SERVICES 55
Class I Services - Diagnostic and Preventive Treatment ......................................................................55
Class II Restorative Services - Basic and Restorative Treatment 55
Class 11 Complicated Services - Complicated Treatment 55
Class III Services - Major Treatment 56
ORTHODONTIA BENEFITS 56
EXCLUDED DENTAL SERVICES 56
CLAIMS Procedures 59
Questions about Your Claims ................................................................................................................59
Types of Claims .....................................................................................................................................60
How to File a Claim ................................................................................................................................60
Incomplete Claims .................................................................................................................................62
Notification of Benefit Determination .....................................................................................................62
Adverse Benefit Determination ..............................................................................................................63
Your Right to Appeal ..............................................................................................................................63
Resources For Information And Assistance ..........................................................................................66
Plan Sponsor's Discretionary Authority; Standard of Review ................................................................67
Coordination of Benefits .........................................................................................................................67
Order of Payment When Coordinating with Other Group Health Plans ................................................68
OTHER IMPORTANT PLAN PROVISIONS 69
Assignment of Benefits ..........................................................................................................................69
Proof of Loss ..........................................................................................................................................69
No Verbal Modifications of Plan Provisions ...........................................................................................69
Reimbursement to the Plan 70
Subrogation 70
Recovery of Excess Payments ..............................................................................................................71
Right To Receive and Release Necessary Information 71
Reliance on Documents and Information ...............................................................................................71
No Waiver ..............................................................................................................................................71
Physician/Patient Relationship ..............................................................................................................72
Plan not responsible for Quality of Health Care ....................................................................................72
Plan is not a Contract of Employment ...................................................................................................72
Right to Amend or Terminate Plan ........................................................................................................72
Applicable Law .......................................................................................................................................72
PRIVACY AND CONFIDENTIALITY 72
Permitted Disclosures of Protected Health Information to the Plan Sponsor ........................................73
No Disclosure of Protected Health Information to the Plan Sponsorwithout Certification by Plan
Sponsor 73
Conditions of Disclosure of Protected Health Information to the Plan Sponsor ....................................73
Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the Plan
Sponsor 74
Required Separation between the Plan and the Plan Sponsor .............................................................74
DEFINITIONS 74
SingleSource Self-Insured 7
Exhibit'B'
RIGHTS OF PLAN MEMBERS 83
SingleSource Self-Insured 8
Exhibit'B'
Grandfathered Health Plan
The Plan Sponsor believes this plan is a 'grandfathered health plan' under the Patient
Protection and Affordable Care Act (the Affordable Care Act). As permitted by the
Affordable Care Act, a grandfathered health plan can preserve certain basic health
coverage that was already in effect when that law was enacted. Being a grandfathered
health plan means that your plan may not include certain consumer protections of the
Affordable Care Act that apply to other plans, for example, the requirement for the
provision of preventive health services without any cost sharing. However,
grandfathered health plans must comply with certain other consumer protections in the
Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a
grandfathered health plan and what might cause a plan to change from grandfathered
health plan status can be directed to the Plan Sponsor, or you may contact
PacificSource at:
PacificSource Health Plans
PO Box 7068
Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
SingleSource Self-Insured 1
Exhibit'B'
SingleSource Self-Insured 2
Exhibit'B'
MEDICAL BENEFIT SUMMARY
POLICY INFORMATION
Group Name: City of Ashland
Group Number: G0032482
Plan Name: Preferred 90+200 VAR GF 0812
Provider Network: Preferred PSN
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours
Waiting Period for New Employees: 1 st day of the month following one (1) day. A person hired on the
first day of the month is eligible on the first day of the following
month.
ANNUAL DEDUCTIBLE $200 per person / $600 per family
The deductible is an amount of covered medical expenses the member pays each benefit year before the plan's
benefits begin. The deductible applies to all services and supplies except those marked with an asterisk Once a
member has paid a total amount toward covered expenses during the benefit year equal to the per person amount
listed above, the deductible will be satisfied for that person for the rest of that benefit year. Once any covered
family members have paid a combined total toward covered expenses during the benefit year equal to the per
family amount listed above, the deductible will be satisfied for all covered family members for the rest of that benefit
year. Deductible expense is not applied to the out-of-pocket limit.
ANNUAL OUT-OF-POCKET LIMIT
Participating Providers $700 per person / $1,400 per family
Non-participating Providers ..........................................$1,700 per person / $3,400 per family
Only participating provider expense applies to the participating provider out-of-pocket limit and only non-
participating provider expense applies to the non-participating out-of-pocket limit. Once the participating provider
out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is deducted) for
participating and network not available providers for the rest of that benefit year. Once the non-participating
provider out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is
deducted) for non-participating providers for the rest of that benefit year. Deductibles, co-payments, benefits paid in
full and non-participating provider charges in excess of the allowable fee do not accumulate toward the out-of-
pocket limit. Co-payments and non-participating provider charges in excess of the allowable fee will continue to be
the members responsibility even after the out-of-pocket limit is met.
ADDITIONAL ACCIDENT BENEFIT
The first $1,000 of covered expenses within 90 days of an accident is covered at no charge and is not subject to
the deductible. The balance is covered as shown below.
The member is responsible for the above deductible and the following co-payments and co-insurance.
PARTICIPATING PROVIDERS/ NON-PARTICIPATING
SERVICE: NETWORK NOT AVAILABLE. PROVIDERS:
PREVENTIVE CARE
Well Baby/Well Child Care 10% co-insurance 30% co-insurance
Routine Physicals No charge' No charge'
Well Woman Visits No charge' No charge"
Immunizations-0-18 yrs No charge' No charge'
Immunizations - age 19 and over 10% co-insurance 30% co-insurance
Routine Colonoscopy 10% co-insurance 30% co-insurance
PROFESSIONAL SERVICES
Office and Home Visits 10% co-insurance 30% co-insurance
Office Procedures and Supplies 10% co-insurance 30% co-insurance
Surgery 10% co-insurance 30% co-insurance
Outpatient Rehabilitation Services 10% co-insurance 10% co-insurance
HOSPITAL SERVICES
Inpatient Room and Board 10% oo-insurance 30% co-insurance
Inpatient Rehabilitation Services 10% co-insurance 30% co-insurance
Skilled Nursing Facility Care 10% co-insurance 30% co-insurance
SingleSource Self-Insured 3
Exhibit'B'
OUTPATIENT SERVICES
Outpatient Surgery/Services 10% co-insuranre 30% co-insurance
Advanced Diagnostic Imaging 10% co-insurance 30% co-insuranoe
Diagnostic and Therapeutic Radiology 10% co-insurance 30% co-insurance
and Lab
URGENT AND EMERGENCY SERVICES
Urgent Care Center Visits 10% co-insurance 30% co-insurance
Emergency Room Visits $100 co-pay/visit plus $100 co-pay/visit plus
10%co-insurance" 10%co-insurance"
Ambulance, Ground 10% co-insurance 10% co-insurance
Ambulance, Air 10% co-insurance 10% co-insurance
MENTAL HEALTH/CHEMICAL DEPENDENCY SERVICES
Office Visits 10% co-insurance 30% co-insurance
Inpatient Care 10% co-insurance 30% co-insurance
Residential Programs 10% co-insurance 30% co-insurance
OTHER COVERED SERVICES
Allergy Injections 10% co-insurance 30% co-insurance
Durable Medical Equipment 10% co-insurance 30% co-insurance
Home Health Care 10% co-insurance 10% co-insurance
Chiropractic Plus (12 visits/benefit 10% co-insurance 10% co-insurance
year)
" For emergency medical conditions, non-participating providers are paid at the participating
provider level.
Not subject to annual deductible.
Payment to providers is based on the prevailing or contracted PacificSource fee allowance for covered services. Although
participating providers accept the fee allowance as payment in full, non-participating providers may not. Services of non-
participating providers could result in out-of-pocket expense in addition to the cost share above. Network Not Available (NNA)
payment is allowed when PacificSource has not contracted with providers in the geographical area of the member's residence
or work for a specific service or supply. Payment to providers for NNA is based on the usual, customary, and reasonable
charge for the geographical area in which the charge is incurred.
SingleSource Self-Insured 4
Exhibit'B'
PRESCRIPTION BENEFIT SUMMARY
Your Plan Sponsor's health plan includes coverage for prescription drugs and certain other
pharmaceuticals, subject to the information below. Your prescription drug plan qualifies as
creditable coverage for Medicare Part D.
MEMBER COST SHARE (other than for Specialty Drugs)
Each time a covered pharmaceutical is dispensed, you are responsible for the co-payment and/or co-
insurance below:
Tier 1: Tier 1: Tier 1:
Generic Preferred Nonoreferred
From a participating retail pharmacy using the
PacificSource Pharmacy Program (see below):
Up to a 34-day supply: $5 $25 $50
From a participating mail order service (see below):
Up to a 34-day supply: $5 $25 $50
35 to 90-day supply: $10 $50 $100
From a participating retail pharmacy without using Not covered,
the PacificSource Pharmacy Program, or from a except 5-day emergency supply
non-participating pharmacy (see below):
MEMBER COST SHARE FOR SPECIALTY DRUG
Each time a covered specialty drug is dispensed, you are responsible for the co-payment and/or co-
insurance below:
From the participating specialty pharmacy:
Up to a 30-day supply: Same as retail pharmacy co-payment above
From a participating retail pharmacy, from a
participating mail order service, or from a non- Not covered,
participating pharmacy or pharmaceutical service except 5-day emergency supply
provider:
WHAT HAPPENS WHEN A BRAND NAME DRUG IS SELECTED
Regardless of the reason or medical necessity, if you receive a brand name drug or if your physician
prescribes a brand name drug when a generic is available, you will be responsible for the brand name
drug's co-payment and/or co-insurance.
USING THE PACIFICSOURCE PHARMACY PROGRAM
Retail Pharmacy Network
To use the PacificSource pharmacy program, you must show the pharmacy plan number on the
PacificSource ID card at the participating pharmacy to receive your plan's highest benefit level.
When obtaining prescription dugs at a participating retail pharmacy, the PacificSource pharmacy
program can only be accessed through the pharmacy plan number printed on your PacificSource ID
card. That plan number allows the pharmacy to collect the appropriate co-payment and/or co-insurance
from you and bill PacificSource electronically for the balance.
Mail Order Service
This plan includes a participating mail order service for prescription drugs. Most, but not all, covered
prescription drugs are available through this service. Questions about availability of specific drugs may
be directed to the PacificSource Customer Service Department or to the plan's participating mail order
SingleSource Self-Insured 5
Exhibit'B'
service vendor. Forms and instructions for using the mail order service are available from PacificSource
and on PacificSource's website, PacificSource.com.
Specialty Drug Program
PacificSource contracts with a specialty pharmacy services provider for high-cost injectable
medications and biotech drugs. A pharmacist-led CareTeam provides individual follow-up care and
support to covered members with prescriptions for specialty medications by providing them strong
clinical support, as well as the best drug pricing for these specific medications and biotech drugs.
The CareTeam also provides comprehensive disease education and counseling, assesses patient
health status, and offers a supportive environment for patient inquiries.
Participating provider benefits for specialty drugs are available when you use PacificSource's
specialty pharmacy services provider. Specialty drugs are not available through the participating
retail pharmacy network or mail order service. More information regarding PacificSource's
exclusive specialty pharmacy services provider and health conditions and a list of drugs requiring
preauthorization and/or are subject to pharmaceutical service restrictions is on PacificSource's
website, PacificSource.com.
OTHER COVERED PHARMACEUTICALS
Supplies covered under the pharmacy plan are in place of, not in addition to, those same covered
supplies under the medical plan. Member cost share for items in this section are applied on the
same basis as for other prescription drugs, unless otherwise noted.
Diabetic Supplies
• Insulin, diabetic syringes, lancets, and test strips are available.
• Glucagon recovery kits are available for the plan's preferred brand name co-payment.
• Glucostix and glucose monitoring devices are not covered under this pharmacy benefit, but are
covered under the medical plan's durable medical equipment benefit.
Contraceptives'
• Oral contraceptives
• Implantable contraceptives, contraceptive injections, contraceptive patches, and contraceptive rings
are available.
• Diaphragm or cervical caps are available.
Tobacco Cessation
Program specific tobacco cessation medications are covered with active participation in a plan
approved tobacco cessation program (see Preventive Care in the policy's Covered Expenses section).
Orally Administered Anticancer Medications
Orally administered anticancer medications used to kill or slow the growth of cancerous cells are
available. Co-payments for orally administered anticancer medication are applied on the same basis as
for other drugs. Orally administered anticancer medications covered under the pharmacy plan are in
place of, not in addition to, those same covered drugs under the medical plan.
LIMITATIONS AND EXCLUSIONS
• This plan only covers drugs prescribed by a licensed physician (or other licensed practitioner
eligible for reimbursement under your plan) prescribing within the scope of his or her professional
license, except for:
- :.Over-the-counter drugs or other drugs that federal law does not prohibit dispensing without a
prescription (even if a prescription is required under state law).
- Drugs for any condition excluded under the health plan. That includes drugs intended to
promote fertility, treatments for obesity or weight loss, tobacco cessation drugs (except as
specifically provided for under Other Covered Pharmaceuticals), experimental drugs, and drugs
available without a prescription (even if a prescription is provided).
- Some specialty drugs that are not self-administered are not covered by this pharmacy benefit,
but are covered under the medical plan's office supply benefit.
SingleSource Self-Insured 6
Exhibit'B'
- Immunizations (although not covered by this pharmacy benefit, immunizations may be covered
under the medical plan's preventive care benefit).
- Drugs and devices to treat erectile dysfunction.
- Drugs used as a preventive measure against hazards of travel.
- Vitamins, minerals, and dietary supplements, except for prescription prenatal vitamins and
fluoride products, and for services that have a rating of 'A' or'B' from the U.S Preventive
Services Task Force (USPSTF).
• Certain drugs require preauthorization by PacificSource in order to be covered. An up-to-date list of
drugs requiring preauthorization is available on PacificSource's website, PacificSource.com.
• PacificSource may limit the dispensing quantity through the consideration of medical necessity,
generally accepted standards of medical practice, and review of medical literature and
governmental approval status.
• Quantities for any drug filled or refilled are limited to no more than a 34-day supply when purchased
at retail pharmacy or a 90-day supply when purchased through mail order pharmacy service or a
30-day supply when purchased through a specialty pharmacy.
• For drugs purchased at non-participating pharmacies or at participating pharmacies without using
the PacificSource pharmacy program, reimbursement is limited to an allowable fee.
• Non-participating pharmacy charges are not eligible for reimbursement unless you have a true
medical emergency that prevents you from using a participating pharmacy. Drugs obtained at a
non-participating pharmacy due to a true medical emergency are limited to a 5 day supply.
• The member cost share for prescription drugs (co-payments, co-insurance, and service charges)
does not apply to the medical deductible or out-of-pocket limit of the policy. You continue to be
responsible for the prescription drug co-payments and service charges regardless of whether the
policy's out-of-pocket limit is satisfied.
• Prescription drug benefits are subject to your plan's coordination of benefits provision. (For more
information see Claims Payment - Coordination of Benefits in your Summary Plan Description.)
GENERAL INFORMATION ABOUT PRESCRIPTION DRUGS
A drug formulary is a list of preferred medications used to treat various medical conditions. The
formulary for this plan is known as the Preferred Drug List (PDL). The drug formulary is used to help
control rising healthcare costs while ensuring that you receive medications of the highest quality. It is a
guide for your physician and pharmacist in selecting drug products that are safe, effective, and cost
efficient. The drug formulary is made up of name brand products. A complete list of medications
covered under the drug formulary is available on the For Members area on PacificSource's website,
PacificSource.com. The drug formulary is developed by Caremark@ in cooperation with PacificSource.
Non-preferred drugs are covered brand name medications not on the drug formulary.
Generic drugs are equivalent to name brand medications. By law, they must have the same active
ingredients as the brand name medication and are subject to the same standards of their brand name
counterpart. Name brand medications lose their patent protection after a number of years. Any drug
company can then produce the drug, and the manufacturer must pass the same strict FDA standards of
quality and product safety as the original manufacturer. Generic drugs are less expensive than brand
name drugs because there is more competition and there is no need to repeat costly research and
development. Your pharmacist and physician are encouraged to use generic drugs whenever they are
available.
SingleSource Self-Insured 7
Exhibit'B'
SingleSource Self-Insured 8
Exhibit'B'
CHIROPRACTIC CARE BENEFIT SUMMARY
Your plan's chiropractic care benefit allows you to receive treatment from licensed chiropractors for
medically necessary diagnosis and treatment of illness or injury. Refer to the Medical Benefit Summary
for your co-payment and/or co-insurance information.
PacificSource contracts with a network of chiropractors, so you can reduce your out-of-pocket expense
by using one of the participating providers. For a listing of participating chiropractors in your area,
please refer to your plan's participating provider directory, visit our website, Pacificsource.com, or call
our Customer Service Department.
Covered Services
• Chiropractic manipulation, massage therapy, and any laboratory services, x-rays, radiology, and
durable medical equipment provided by or ordered by a chiropractor.
The combined benefit for all treatments, services, and supplies provided or ordered by a chiropractor is
limited to 12 visits per person in any benefit year.
Excluded Services
• Any service or supply excluded or not otherwise covered by the medical plan.
• Drugs, homeopathic medicines, or homeopathic supplies furnished by a chiropractor.
• Services of an alternative care provider for pregnancy or childbirth.
SingleSource Self-Insured 9
Exhibit'B'
SingleSource Self-Insured 10
Exhibit'B'
ADDITIONAL ACCIDENT BENEFIT SUMMARY
In the event of an injury caused by an accident, first dollar benefits are provided for covered expenses
according to the following:
Related Definitions
'Accident' means an unforeseen or unexpected event causing injury that requires medical attention.
'Injury' means bodily trauma or damage which is independent of disease or infirmity. The damage must
be caused solely through external and accidental means. Injury, for the purpose of this benefit, does not
include musculoskeletal sprains or strains obtained in the performance of physical activity.
Covered Expenses
Benefits for the following covered expenses are provided, subject to the limitations stated below:
• Services or supplies provided by a physician (except orthopedic braces)
• Services of a hospital
• Services of a registered nurse who is unrelated to the injured person by blood or marriage
• Services of a registered physical therapist
• Services of a physician or a dentist for the repair of a fractured jaw or natural teeth
• Diagnostic radiology and laboratory services
• Transportation by local ground ambulance
Limitations
• The treatment must be medically necessary for the injury.
• The treatment or service must be provided within 90 days after the injury occurs.
• The first $1,000 of covered expense is paid at 100% and is not subject to the deductible.
SingleSource Self-Insured 11
Exhibit'B'
SingleSource Self-Insured 12
Exhibit'B'
VISION BENEFIT SUMMARY
Your Plan Sponsor covers vision exams, eyeglasses, and contact lenses. The following shows the
vision benefits available.
Benefit Period
Eye Exam: Once every 12 months for covered children. Once every 24 months for
covered adults.
Lenses: Once every 12 months for covered children. Once every 24 months for
covered adults.
Frames: Once every 24 months for all covered individuals OR
Contact lenses: Once every 12 months for covered children. Once every 24 months for
covered adults.
Member Responsibility
PARTICIPATING NON-PARTICIPATING
SERVICE/SLIPPLY PROVIDERS: PROVIDERS:
Eye Exam No charge No charge up to a
$71 maximum
Hardware
Lenses (maximum per pair)
Single Vision No charge No charge up to a
$51 maximum
Bifocal No charge No charge up to a
$77 maximum
Trifocal No charge No charge up to a
$100 maximum
Lenticular No charge Not covered
Progressive No charge Not covered
Frames No charge up to a No charge up to a
$120 maximum $66 maximum
Contacts (in place of No charge up to a No charge up to a
glasses) $166 maximum $166 maximum
The amounts listed above are the maximum benefits available for all vision exams, lenses, and
frames furnished during any benefit period when prescribed by a licensed ophthalmologist or
licensed optometrist. Participating providers discount hardware services.
Limitations and Exclusions
The out-of-pocket expense for vision services (co-payments and service charges) does not apply
to the medical plan's deductible or out-of-pocket limit. Also, the member continues to be
responsible for the vision co-payments and service charges regardless of whether the medical
plan's out-of-pocket limit is satisfied.
Covered expenses do not include, and no benefits are payable for:
• Special procedures such as orthoptics or vision training
• Special supplies such as sunglasses (plain or prescription) and subnormal vision aids
• Tint
SingleSource Self-Insured 13
Exhibit'B'
• Plano contact lenses
• Anti-reflective coatings and scratch resistant coatings
• Separate charges for contact lens fitting
• Replacement of lost, stolen, or broken lenses or frames
• Duplication of spare eyeglasses or any lenses or frames
• Nonprescription lenses
• Visual analysis that does not include refraction
• Services or supplies not listed as covered expenses
• Eye exams required as a condition of employment, or required by a labor agreement or government
body
• Expenses covered under any worker's compensation law
• Services or supplies received before this plan's coverage begins or after it ends
• Charges for services or supplies covered in whole or in part under any other medical or vision
benefits provided by the Plan Sponsor
• Medical or surgical treatment of the eye
Important information about your vision benefits
Your Plan Sponsor's health plan includes coverage for vision services, including prescription
eyeglasses and contact lenses. To make the most of those benefits, it's important to keep in mind
the following:
• Participating Providers
PacificSource is able to add value to your vision benefits by contracting with a network of vision
providers. Those providers offer vision services at discounted rates, which are passed on to you in
your benefits.
• Paying for Services
Please remember to show your current PacificSource ID card whenever you use your plan's
benefits. PacificSource's provider contracts require participating providers to bill us directly
whenever you receive covered services and supplies. Providers normally call PacificSource to
verify your vision benefits. Participating providers should not ask you to pay the full cost in
advance. They may only collect your share of the expense up front, such as copayments and
amounts over your plan's allowances. If you are asked to pay the entire amount in advance,
tell the provider you understand they have a contract with PacificSource and should bill
PacificSource directly.
• Sales and Special Promotions
Vision retailers often use coupons and promotions to bring in new business, such as free eye
exams, two-for-one glasses, or free lenses with purchase of frames. Because participating
providers already discount their services through their contract with PacificSource, your plan's
participating provider benefits cannot be combined with any other discounts or coupons. You can
use your plan's participating provider benefits, or you can use your plan's non-participating provider
benefits to take advantage of a sale or coupon offer. If you do take advantage of a special offer, the
participating provider may treat you as an uninsured customer and require full payment in advance.
You can then send the claim to PacificSource yourself, and PacificSource will reimburse you
according to your plan's non-participating provider benefits.
PacificSource hopes this information helps clarify your vision benefits. If you or your provider have any
questions about your benefits, please call PacificSource Customer Service at (541) 686-1242 from
Eugene-Springfield or (888) 977-9299 from other areas.
SingleSource Self-Insured 14
Exhibit'B'
DENTAL BENEFIT SUMMARY
POLICY INFORMATION
Group Name: City of Ashland
Group Number: G0032482
Plan Name: Preferred Incentive Dental $1500 VAR 0711
EMPLOYEE ELIGIBILITY REQUIREMENTS
Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours
Waiting Period for New Employees: 1 st day of the month following one (1) day. A person hired on the
first day of the month is eligible on the first day of the following
month.
DENTAL BENEFIT SUMMARY
Subject to all the terms of this Group Dental Policy, the Plan Sponsor will pay a dental benefit for
covered dental expenses incurred by a covered person. The dental benefit is a percentage of the usual,
customary, and reasonable charge for covered dental expenses incurred, subject to an annual
maximum benefit, and an annual deductible, as follows:
Maximum Payment
The amount payable by this plan for covered services received under Class I are unlimited. The
maximum amount payable by this plan for covered Class II and Class III services received each benefit
year, or portion thereof, for each eligible patient is limited to $1,500.
PLAN PAYMENT SCHEDULE
Class I Services- Plan pays 70% toward covered Class I Services - Diagnostic and
Preventive Treatment.
Class II Restorative Services- Plan pays 70% toward covered Class II Restorative Services -
Restorative Treatment.
Class II Complicated Services- Plan pays 70% toward covered Class II Complicated Services -
Complicated Treatment.
Class III Services- Plan pays 70% toward covered Class III Services - Major Treatment.
This plan pays the percentage indicated above toward Class I, II and III Services during the first year an
individual is eligible. Payment increases 10 percent (to a maximum benefit of 100 percent) each
successive benefit year for Class I, II and III Services if the member visits a dentist at least once during
the benefit year. Payment decreases 10 percent (to a minimum benefit of the percentage stated above)
each successive benefit year if the member does not visit a dentist at least once during the previous
benefit year.
SingleSource Self-Insured 15
Exhibit'B'
SingleSource Self-Insured 16
Exhibit V
ORTHODONTIA BENEFITS
Covered Charges
The Plan Sponsor will pay 50% of the usual, customary and reasonable for orthodontics for all covered
individuals.
Lifetime Maximum
The maximum amount payable by the Plan Sponsor for orthodontic benefits to an eligible patient is
$1,000 per lifetime.
Exclusions and Limitations
• The Plan Sponsorwill cease making payment for orthodontic treatment if the treatment ends for
any reason prior to the completion of your case.
• The Plan Sponsor will not make any payments for the repair or replacement of an orthodontic
appliance that was furnished under this coverage.
• The Plan Sponsor's monthly or periodic payments for orthodontics shall cease if your eligibility
is terminated.
• The Plan Sponsor's obligation to make payments for orthodontic treatment that began prior to
your eligibility date is calculated based on remaining balance at your initial eligibility date. The
calculation will take into account the dentist's or orthodontist's normal payment pattern. The
above-mentioned maximum will apply to this amount.
SingleSource Self-Insured 17
Exhibit'B'
SingleSource Self-Insured 18
Exhibit 'B'
USING THE PROVIDER NETWORK
This section explains how your plan's benefits differ when you use participating and non-participating
providers. This information is not meant to prevent you from seeking treatment from any provider if you
are willing to take increased financial responsibility for the charges incurred.
All healthcare providers are independent contractors. Neither your Plan Sponsor nor PacificSource can
be held liable for any claim or damages for injuries you experience while receiving medical care.
Preferred Provider Organization (PPO)
What is a PPO
A preferred provider organization (PPO) has made agreements with hospitals, physicians, practitioners,
and other health care providers to discount the cost of services they provide.
Who is Your PPO
The Plan Sponsor has chosen PacificSource to provide PPO services for employees and eligible
dependents in Oregon, Idaho, and Montana service areas and in bordering communities in southwest
Washington. They also have an agreement with a nationwide provider network, The First Health®
Network. The First Health providers outside PacificSource's service area are also considered
participating providers under your plan.
A list of participating providers can be accessed through the PacificSource website: PacificSource.com
or by calling PacificSource at (888) 977-9299. This list of participating providers is updated regularly.
About Your PIRO
PacificSource has selected the participating physicians, practitioners, and hospitals after carefully
reviewing their qualifications. Each health care provider has agreed to a contracted amount in payment
for their services. Additionally, you cannot be 'balanced billed' for the difference between the PPO
contracted amount and the provider's normal billed charge for a particular service. You are only
responsible for the deductible, copayment, and/or coinsurance payment shown on the Medical Benefit
Summary.
Enrolling in this plan does not guarantee that a particular participating providerwill remain a
participating provideror that a particular participating providerwill provide members under this plan only
with covered services. Members should verify a health care provider's status as a participating provider
each time services are received from the health care provider.
It is not safe to assume that when you are treated at a participating medical facility, all services are
performed by participating providers. A list of participating providers can be accessed through the
PacificSource website: PacificSource.com or by calling PacificSource at (888) 977-9299. Whenever
possible, you should arrange for professional services such as surgery and anesthesiology to be
provided by a participating provider. Doing so will help you maximize your benefits and limit your out-of-
pocket expenses. The PPO benefits are outlined on the Medical Benefit Summary.
You have a free choice of any health care provider, and the physician-patient relationship shall be
maintained. Members, together with their health care provider, are ultimately responsible for
determining the appropriate course of medical treatment, regardless of whether the plan will pay for all
or a portion of the cost of such care. The participating providers are merely independent contractors;
neither the plan, the Plan Sponsor, nor PacificSource makes any warranty as to the quality of care that
may be rendered by any participating provider. .
This plan generally allows the designation of a primary care provider. You have the right to designate
any primary care provider who participates in the network and who is available to accept you or your
family members. For children, you may designate a pediatrician as the primary care provider. You do
not need prior authorization from this plan or from any other person (including a primary care provider)
in order to obtain access to obstetrical or gynecological care from a health care professional in the
network who specializes in obstetrics or gynecology. The health care 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 for making referrals. For a list of the
SingleSource Self-Insured 19
Exhibit B'
participating providers and/or a list of participating health care professionals who specialize in obstetrics
or gynecology, contact PacificSource at (888) 977-9299 or PO Box 7068, Springfield, OR 97475-0068.
Non-PPO Providers
When you receive services or supplies from a nonparticipating provider, your out-of-pocket expense is
likely to be higher than if you had used a participating provider. Besides the non-PPO deductible,
copayment, and/or coinsurance amounts shown on the Medical Benefit Summary, you may become
responsible for the provider's billed amount that exceeds the plan's allowable amount.
Example of Provider Payment
The following illustrates how payment could be made for a covered service billed at $120. In this
example, the Medical Benefit Summary shows a participating providers co-insurance of 20 percent and
a non-participating providers co-insurance of 30 percent. This is only an example; your plan's benefits
may be different.
Participating Non-participating
Provider Provider
Provider's usual billed charge $120 $120
PPO's negotiated provider discount $20 $0
Plan's allowable amount $100 $100
Percent of payment 20% 30%
Plan's payment $80 $70
Patient's amount of allowable amount $20 $30
Charges above the allowable amount $0 $20
Patient's total payment to provider $20 $50
Percent of charge paid by plan 80% 58%
Percent of charge paid by patient 20% 42%
Allowable Amount
The plan bases payment to nonparticipating providers on an allowable amount for the same services or
supplies. Several sources are used to determine the allowable amount, depending on the service or
supply and the geographical area where it is provided. The allowable amount may be based on data
collected from the Centers for Medicare and Medicaid Services (CMS), Viant Health Payment
Solutions, other nationally recognized databases, or PacificSource.
NETWORK NOT AVAILABLE BENEFITS
The term 'network not available' is used when a member does not have reasonable geographic access
to a participating provider for a covered medical service or supply.
If you live in an area without access to a participating provider for a specific service or supply, your
plan's Network Not Available benefits apply. Here's how that works:
• You seek treatment from a nearby non-participating provider of that service or supply.
• PacificSource determines the allowable fee for that service or supply (the term 'allowable fee' is
explained above under the Non-participating Providers section).
• PacificSource applies the Network Not Available benefit level stated in your Medical Benefit
Summary to the allowable fee to calculate covered expenses.
• You are responsible for any co-payments, co-insurance, deductibles, and amounts over the
allowable fee.
COVERAGE WHILE TRAVELING
Your plan is powered by the PacificSource Network (PSN). The PSN Network covers Oregon, Idaho,
Montana, southwest Washington, and eastern Washington. When you need medical services outside of
the PSN Network, you can save out-of-pocket expense by using the participating providers available
through The First HealthO Network.
SingleSource Self-Insured 20
Exhibit'B'
Nenemergency Care While Traveling
To find a participating provider outside the regions covered by the PacificSource Network, call The First
Health® Network at (800) 226-5116. (The phone number is also printed on your PacificSource ID card
for convenience.) Representatives are available at any time to help you find a participating physician,
hospital, or other outpatient provider. Nonemergency care outside of the United States is not covered.
• If a participating provider is available in your area, your plan's participating provider benefits will
apply if you use a participating provider.
• If a participating provider is not available in your area, your plan's Network Not Available benefits
will apply.
• If a participating provider is available but you choose to use a non-participating provider, your plan's
non-participating provider benefits will apply.
Emergency Services While Traveling
In medical emergencies (see the Covered Expenses - Emergency Services section of this Summary
Plan Description), your plan pays benefits at the participating provider level regardless of your location.
Your covered expenses are based on PacificSource's allowable fee. If you are admitted to a hospital as
an inpatient following the stabilization of your emergency condition, your physician or hospital should
contact the PacificSource Health Services Department at (888) 691-8209 as soon as possible to make
a benefit determination on your admission. If you are admitted to a non-participating hospital,
PacificSource may require you to transfer to a participating facility once your condition is stabilized in
order to continue receiving benefits at the participating provider level.
FINDING PARTICIPATING PROVIDER INFORMATION
You can find up-to-date participating provider information:
• By asking your healthcare provider if he or she is a participating provider for your Plan Sponsor's
plan.
• On the PacificSource website, PacificSource.com. Simply click on 'Find a Provider' and you can
easily look up participating providers or print your own customized directory.
• By contacting the PacificSource Customer Service Department. PacificSource can answer your
questions about specific providers. If you'd like a complete provider directory for your plan, just ask
- PacificSource will be glad to mail you a directory free of charge.
• By calling The First Health® Network at (800) 226-5116 if you live outside the area covered by the
PacificSource Network.
TERMINATION OF PROVIDER CONTRACTS
PacificSource will notify you within ten days of learning of the termination of a provider contractual
relationship if you have received services in the previous three months from such a provider when:
• A provider terminates a contractual relationship with PacificSource in accordance with the terms
and conditions of the agreement,
• A provider terminates a contractual relationship with an organization under contract with
PacificSource; or
• PacificSource terminates a contractual relationship with an individual provider or the organization
with which the provider is,contracted in accordance with the terms and conditions of the agreement.
For the purposes of continuity of care, PacificSource may require the provider to adhere to the medical
services contract and accept the contractual reimbursement rate applicable at the time of contract
termination.
SingleSource Self-Insured 21
Exhibit'B'
BECOMING ELIBIGLE
Who Pays for Your Benefits
The Plan Sponsor shares the cost of providing benefits for you and your enrolled dependents. From
time to time, the Plan Sponsor may adjust the amount of contributions required for coverage. In
addition, the deductibles and copayments may also change periodically. You will be notified by your
Plan Sponsor of any changes in the cost of plan coverage before they take effect.
Who is Eligible
Employees -You are eligible to participate in this plan if you are a regular, full-time employee of the
Plan Sponsor upon the completion of the minimum number of hours and probationary waiting period set
by your Plan Sponsor. Your Plan Sponsors eligibility requirements are stated in your Medical Benefit
Summary. All employees who meet those requirements are eligible for coverage.
Eligibility for Medicaid or the receipt of Medicaid benefits will not be taken into account in determining
eligibility. Status as an employee is determined under the employment records of the Plan Sponsor.
Workers classified by the Plan Sponsor as independent contractors are not eligible for this plan under
any circumstances.
Retirees - You are eligible to participate in this plan if you are a retired employee of the Plan Sponsor,
or a spouse of a retired employee. Eligibility for Medicaid or the receipt of Medicaid benefits will not be
taken into account in determining eligibility.
Dependents - While you are enrolled under this plan, the following family members, and only the
following family members, are also eligible to participate in the plan:
• Your legal spouse or qualified domestic partner. The Plan Sponsor may require documentation
proving a legal marital relationship, an Affidavit of Domestic Partnership or a Certificate of Qualified
domestic partnership.
• Your, your spouse's, or your qualified domestic partner's dependent children under age 26
regardless of the child's place of residence, marital status, or financial dependence on you.
• Your, your spouse's, or your qualified domestic partner's unmarried dependent children age 26 or
over who are mentally or physically disabled. To qualify as dependents, they must have been
continuously unable to support themselves since turning age 26 because of a mental or physical
disability. PacificSource requires documentation of the disability from the child's physician, and will
review the case before determining eligibility for coverage.
• Your grandchildren. A child of an eligible dependent enrolled on your plan under age 19 who is
unmarried, not in a domestic partnership, registered or otherwise, who is related to you by blood,
marriage, or domestic partnership AND for whom you are the court appointed legal custodian or
guardian with the expectation that the family member will live in your household for at least a year.
• A child placed for adoption with you, your spouse, or qualified domestic partner. Placed for
adoption means the assumption and retention by you, your spouse, or qualified domestic partner of
a legal obligation for total or partial support of a child in anticipation of adoption or placement for
adoption. Upon any termination of such legal obligations the placement for adoption shall be
deemed to have terminated.
• 'Dependent children' means any natural, step, or adopted children as well as any child placed for
adoption with you or your domestic partner are legally obligated to support or contribute support for.
It may also include grandchildren under age 19 who are unmarried and expected to live in your
household for at least a year, if you are the court appointed legal custodian or guardian.
No family or household members other than those listed above are eligible to enroll under your
coverage.
Special Rules for Eligibility - At any time, the Plan Administrator may require proof that a person
qualifies or continues to qualify as a dependent as defined by this plan.
SingleSource Self-Insured 22
Exhibit'B'
ENROLLING DURING THE INITIAL ENROLLMENT PERIOD
The 'initial enrollment period' is the 60-day period beginning on the date a person is first eligible for
enrollment in this plan. Everyone who becomes eligible for coverage has an initial enrollment period.
When you satisfy your Plan Sponsor's probationary waiting period at the hours required for eligibility
and become eligible to enroll in this plan, you and your eligible family members must enroll within the
initial enrollment period. If you miss your initial enrollment period, you may be subject to a waiting
period. (For more information, see 'Special Enrollment Periods' and 'Late Enrollment' under the
Enrolling After the Initial Enrollment Period section.) To enroll, you must complete and sign an
enrollment application, which is available from your Plan Sponsor. The application must include
complete information on yourself and your enrolling family members. Return the application to your
Plan Sponsor, and your Plan Sponsorwill send it to PacificSource.
Coverage for you and your enrolling family members begins on the first day of the month after you
satisfy your Plan Sponsor's probationary waiting period. The probationary waiting period is stated in
your Medical Benefit Summary. Coverage will only begin if Your Plan Sponsor receives your enrollment
application and premium.
Newborns
Your, your spouse's, or your qualified domestic partner's natural born baby is eligible for
enrollment under this plan during the 60-day initial enrollment period after birth. PacificSource
cannot enroll the child and pay benefits until your Plan Sponsor receives an enrollment application
listing the child as your dependent. A claim for maternity care is not considered notification for the
purpose of enrolling a newborn child. Anytime there is a delay in providing enrollment information,
your Plan Sponsor may ask for legal documentation to confirm validity.
Adopted Children
When a child is placed in your home for adoption, the child is eligible for enrollment under this plan
during the 60-day initial enrollment period after placement for adoption. 'Placement for adoption' means
the assumption and retention by you, your spouse's, or your domestic partner's of a legal obligation for
full or partial support and care of the child in anticipation of adoption of the child. To add the child to
your coverage, you must complete and submit an enrollment application listing the child as your
dependent. You may be required to submit a copy of the certificate of adoption or other legal
documentation from a court or a child placement agency to complete enrollment.
If additional premium is required, then the natural born or adopted child's eligibility for enrollment will
end 60 days after placement if Plan Sponsor has not received an enrollment application and premium.
Premium is charged from the date of placement and prorated for the first month.
If no additional premium is required, then the natural born or adopted child's eligibility continues as long
as you are covered. However, PacificSource cannot enroll the child and pay benefits until your Plan
Sponsor receives an enrollment application listing the child as your dependent.
Family Members Acquired by Marriage
If you marry, you may add your new spouse and any newly eligible dependent children to your
coverage during the 60-day initial enrollment period after the marriage. Your Plan Sponsor must receive
your enrollment application and additional premium during the initial enrollment period. Coverage for
your new family members will then begin on the first day of the month after the marriage. You may be
required to submit a copy of your marriage certificate to complete enrollment.
Family Members Acquired by Domestic Partnership
If you and your same-gender domestic partner have been issued a Certificate of Qualified domestic
partnership, your domestic partner and your partner's dependent children are eligible for coverage
during the 60-day initial enrollment period after the registration of the domestic partnership. Your Plan
Sponsor must receive your enrollment application and additional premium during the initial enrollment
period. Coverage for your new family members will then begin on the first day of the month after the
registration of the domestic partnership. You may be required to submit a copy of your Certificate of
Qualified domestic partnership to complete enrollment.
SingleSource Self-Insured 23
Exhibit'B'
Unregistered same-gender domestic partners and their children may also become eligible for
enrollment. If you and your unqualified domestic partner meet the criteria on the Affidavit of Domestic
Partnership supplied by your Plan Sponsor, your domestic partner and your partner's dependent
children are eligible for coverage during the 60-day initial enrollment period after the requirements of
the Affidavit of Domestic Partnership are satisfied. Your Plan Sponsor must receive your enrollment
application, a notarized copy of your Affidavit of Domestic Partnership, and additional premium during
the initial enrollment period. Coverage for your new family members will then begin on the first day of
the month after the Affidavit of Domestic Partnership is notarized.
Family Members Placed in Your Guardianship
If a court appoints you custodian or guardian of an eligible grandchild, you may add that family member
to your coverage. To be eligible for coverage, the family member must be:
• Unmarried;
• Not in a domestic partnership, registered or otherwise;
• Related to you by blood, marriage, or domestic partnership;
• Under age 19; and
• Expected to live in your household for at least a year.
Your Plan Sponsor must receive your enrollment application and additional premium during the 60-day
initial enrollment period beginning on the date of the court appointment. Coverage will then begin on the
first day of the month following the date of the court order. You may be required to submit a copy of the
court order to complete enrollment.
Qualified Medical Child Support Orders
This health plan complies with qualified medical child support orders (QMCSO) issued by a state court
or state child support agency. A QMCSO is a judgment, decree, or order, including approval of a
settlement agreement that provides for health benefit coverage for the child of a plan member.
If a court or state agency orders coverage for your spouse or child, they may enroll in this plan within
the 60-day initial enrollment period beginning on the date of the order. Coverage will become effective
on the first day of the month after Plan Sponsor receives the enrollment application. You may be
required to submit a copy of the QMCSO to complete enrollment.
ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD
Returning to Work after a Layoff
If you are laid off and then rehired by your Plan Sponsor within six months, you will not have to satisfy
another probationary waiting period or new exclusion period.
Your health coverage will resume the first of the month following the date you return to work and again
meet your Plan Sponsors minimum hour requirement. If your family members were covered before
your layoff, they can resume coverage at that time as well. You must re-enroll your family members by
submitting an enrollment application within the 60-day initial enrollment period following your return to
work.
Returning to Work after a Leave of Absence
If you return to work after a Plan Sponsor-approved leave of absence of six months or less, you will not
have to satisfy another probationary waiting period. Your health coverage will resume the day you
return to work and again meet your Plan Sponsor's minimum hour requirement. If your family members
were covered before your leave of absence, they can resume coverage at that time as well. You must
re-enroll your family members by submitting an enrollment application within the 60-day initial
enrollment period following your return to work.
Retuming to Work after Family Medical Leave
Your Plan Sponsor is probably subject to the Family Medical Leave Act (FMLA). To find out if you have
rights under FMLA, ask your health plan administrator. Under FMLA, if you return to work after a
SingleSource Self-Insured 24
Exhibit 'B'
qualifying FMLA medical leave, you will not have to satisfy another probationary waiting period or any
previously satisfied exclusion period under this plan. Your health coverage will resume the day you
return to work and meet your Plan Sponsor's minimum hour requirement. If your family members were
covered before your leave, they can also resume coverage at that time if you re-enroll them within the
60-day initial enrollment period following your return.
Special Enrollment Periods
If you are eligible to decline coverage and you wish to do so, you must submit a written waiver of
coverage to your Plan Sponsor. You and your family members may enroll in this plan later if you qualify
under Rule #1, Rule #2, or Rule #3 below.
• Special Enrollment Rule #1 - If you declined enrollment for yourself or your family members
because of other health insurance coverage, you or your family members may enroll in the plan
later if the other coverage ends involuntarily. 'Involuntarily' means coverage ended because
continuation coverage was exhausted, employment terminated, work hours were reduced below
the Plan Sponsor's minimum requirement, the other insurance plan was discontinued or the
maximum lifetime benefit of the other plan was exhausted, the Plan Sponsors premium
contributions toward the other insurance plan ended, or because of death of a spouse, divorce, or
legal separation. To do so, you must request enrollment within 60 days after the other health
insurance coverage ends (or within 60 days after the other health insurance coverage ends if the
other coverage is through Medicaid or a State Children's Health Insurance Program). Coverage will
begin on the first day of the month after the other coverage ends.
• Special Enrollment Rule #2 - If you acquire new dependents because of marriage, qualification of
domestic partnership, birth, or placement for adoption, you may be able to enroll yourself and/or
your newly acquired eligible dependents at that time. To do so, you must request enrollment within
60 days after the marriage, registration of the domestic partnership, birth, or placement for
adoption. In the case of marriage or domestic partnership, coverage begins on the first day of the
month after the marriage or registration of the domestic partnership. In the case of birth or
placement for adoption, coverage begins on the date of birth or placement.
• Special Enrollment Rule #3 - If you or your dependents become eligible for a premium assistance
subsidy under Medicare or CHIP, you may be able to enroll yourself and/or your dependents at that
time. To do so, you must request enrollment within 60 days of the date you and/or your dependents
become eligible for such assistance. Coverage will begin on the first day of the month after
becoming eligible for such assistance.
Dental Enrollment
Employees or their dependents who did not enroll with dental benefits when initially eligible may later
enroll on the policy's anniversary date. Employees and/or dependents who enrolled with dental benefits
under this policy but later terminated coverage may enroll on an anniversary date of the policy following
a 24-month waiting period from the date coverage was last terminated.
Late Enrollment
If you did not enroll during your initial enrollment period and you do not qualify for a special
enrollment period, your enrollment will be delayed until the plan's anniversary date.
A'late enrollee' is an otherwise eligible employee or dependent who does not qualify for a special
enrollment period explained above, and who:
• Did not enroll during the 60-day initial enrollment period; or
• Enrolled during the initial enrollment period but discontinued coverage later.
A late enrollee may enroll by submitting an enrollment application to your Plan Sponsor during an open
enrollment period designated by your Plan Sponsorjust prior to the plan's anniversary date. When you
or your dependents enroll during the open enrollment period, plan coverage begins on the date Plan
Sponsor receives the enrollment application or on the plan's anniversary date.
You may enroll in coverage prior to an open enrollment period if one of the following exceptions are
met:
SingleSource Self-Insured 25
Exhibit'B'
• You and/or your dependent may enroll in coverage if you involuntary lose other Group Coverage or
lose coverage under the Oregon Health Plan.
• You and/or your dependent may enroll in coverage if your hours per week are increased or your
employer's contribution is increased. You and/or your dependent may also enroll if you return from
a qualified FMLA leave.
Member ID Card
The membership card issued to you by PacificSource is for identification purposes only. Possession of
a membership card confers no right to services or benefits under this plan and misuse of your
membership card may be grounds for termination of your coverage under this plan. To be eligible for
services or benefits under this plan, you must be eligible and enrolled in the plan and you must present
the membership card to your health care provider. If you receive services or benefits for which you are
not entitled to receive under the terms of this plan, you may be charged for such services or benefits at
the prevailing rate. If you permit the use of your membership card by any other person, your card may
be retained by this plan, and all your rights under this plan may be terminated.
PLAN SELECTION PERIOD
If your Plan Sponsor offers more than one benefit plan option, you may choose another plan option only
upon your plan's anniversary date. You may select a different plan option by completing a selection
form or application form. Coverage under the new plan option becomes effective on your plan's
anniversary date.
TERMINATING COVERAGE
If you leave your job for any reason or your work hours are reduced below your Plan Sponsor's
minimum requirement, coverage for you and your enrolled family members will end. Coverage ends on
the last day of the last month in which you worked full time. You may, however, be eligible to continue
coverage for a limited time, please see the Continuation section of this Summary Plan Description for
more information.
You can voluntarily discontinue coverage for your enrolled family members at any time by completing a
Termination of Dependent Coverage form and submitting it to your Plan Sponsor. Keep in mind that
once coverage is discontinued, your family members may be subject to the late enrollment waiting
period if they wish to re-enroll later.
Divorced Spouses
If you divorce, coverage for your spouse will end on the last day of the month in which the divorce
decree or legal separation is final. You must notify your Plan Sponsor of the divorce or separation, and
continuation coverage may be available for your spouse. If there are special child custody
circumstances, please contact your Plan Sponsor. Please see the Continuation section for more
information.
Dependent Children
When your enrolled child no longer qualifies as a dependent, coverage will end on the last day
of that month. Please see the Eligibility section of this Summary Plan Description for information
on when your dependent child is eligible beyond age 25. The Continuation section includes
information on other coverage options for those who no longer qualify for coverage.
Dissolution of Domestic Partnership
If you dissolve your domestic partnership, coverage for your domestic partner and their children not
related to you by birth or adoption will end on the last day of the month in which the dissolution of the
domestic partnership is final. You must notify your Plan Sponsor of the dissolution of the domestic
partnership. Under Oregon state continuation laws, a qualified domestic partner and their covered
children may continue this policy's coverage under the same circumstances and to the same extent
afforded an enrolled spouse and their enrolled children (see Oregon Continuation in the Continuation of
Insurance section). Domestic partners and their covered children are not recognized as qualified
beneficiaries under federal COBRA continuation laws. Domestic partners and their covered children
SingleSource Self-Insured 26
Exhibit'&
may not continue this policy's coverage under COBRA independent of the employee (see COBRA
Continuation in the Continuation of Insurance section).
Cerdricates of Creditable Coverage
A certificate of creditable coverage is used to verify the dates of your prior health plan coverage
when you apply for coverage under a new policy. These certificates are issued by health
insurers whenever a plan participant's coverage ends. After your or your dependent's coverage
under this plan ends, you will receive a certificate of creditable coverage by mail. PacificSource
has an automated process that generates and mails these certificates whenever coverage ends.
PacificSource will send a separate certificate for any dependents with an effective or termination
date that differs from yours. For questions or requests regarding certificates of creditable
coverage, you are welcome to contact Membership Services Department at (541) 684-5583 or
(866) 999-5583.
CONTINUATION OF INSURANCE
Under federal and state laws, you and your family members may have the right to continue this
plan's coverage for a specified time. You and your dependents may be eligible if:
• Your employment ends or you have a reduction in hours
• You take a leave of absence for military service
• You divorce
• You die
• You become eligible for Medicare benefits if it causes a loss of coverage for your dependents
• Your children no longer qualify as dependents
The following sections describe your rights to continuation under state and federal laws, and
the requirements you must meet to enroll in continuation coverage.
USERRA CONTINUATION
If you take a leave of absence from your job due to military service, you have continuation rights under
the Uniformed Services Employment and Re-employment Rights Act (USERRA).
You and your enrolled family members may continue this plan's coverage if you, the employee, no
longer qualify for coverage under the plan because of military service. Continuation coverage under
USERRA is available for up to 24 months while you are on military leave. If your military service ends
and you do not return to work, your eligibility for USERRA continuation coverage will end. Premium for
continuation coverage is your responsibility.
The following requirements apply to USERRA continuation:
• Family members who were not enrolled in the group plan cannot take continuation. The only
exceptions are newborn babies and newly acquired dependents not covered by another group
health plan.
• To apply for continuation, you must submit a completed Continuation Election Form to your Plan
Sponsorwithin 31 days after the last day of coverage under the group plan.
• You must pay continuation premium to your Plan Sponsor by the first of each month. Your Plan
Sponsor will include your continuation premium in the group's regular monthly payment.
PacificSource cannot accept the premium directly from you.
• Your Plan Sponsor must still be self-insured through PacificSource. If your Plan Sponsor
discontinues this plan, you will no longer qualify for continuation.
SingleSource Self-Insured 27
Exhibit'B'
Surviving or Divorced Spouses and QualiFed Domestic Partners
If you die, divorce, or dissolve your qualified domestic partnership, and your spouse or qualified
domestic partner is 55 years or older, your spouse or qualified domestic partner may be able to
continue coverage until eligible for Medicare or other coverage. Dependent children are subject to the
health plan's age and other eligibility requirements. Some restrictions and guidelines apply; please see
your Plan Sponsorfor specific details.
COBRA CONTINUATION
Your Plan Sponsor is subject to the continuation of coverage provisions of the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA) as amended. To find out if you have continuation rights
under COBRA, ask your health plan administrator.
COBRA Eligibility
To be eligible, a member must experience a'qualifying event' which is an event that causes your
regular group coverage to end and makes you eligible for continuation coverage. When the following
qualifying events happen, you may continue coverage for the lengths of time shown:
Qualifying Event Continuation Period
Employee's termination of employment or reduction in Employee, spouse, and children may continue for up to
hours 18 months'
Employee's divorce or legal separation Souse and children may continue for u to 36 months
Employee's eligibility for Medicare benefits if it causes a Spouse and children may continue for up to 36 months
loss of coverage
Employee's death Souse and children may continue for u to 36 months
Child no longer qualifies as a dependent Child may continue for u to 36 months
Em to er files for Cha ter 11 bankruptcy Only applies to retirees and their covered dependents
If the employee or covered dependent is determined disabled by the Social Security Administration within the first
60 days of continuation coverage, all qualified beneficiaries may continue coverage for up to an additional 11
months, for a total of up to 29 months.
2 The total maximum continuation period is 36 months, even if there is a second qualifying event. A second
qualifying event might be a divorce, legal separation, death, or child no longer qualifying as a dependent after the
employee's termination or reduction in hours.
If your dependents were not covered prior to your qualifying event, they may enroll in the continuation
coverage while you are on continuation. They will be subject to the same rules that apply to active
employees, including the late enrollment waiting period.
If your employment is terminated for gross misconduct, you and your dependents are not eligible for
COBRA continuation.
Domestic partners and their covered children may not continue this policy's coverage under COBRA
independent of the employee.
When Continuation Coverage Ends
Your continuation coverage will end before the end of the continuation period above if any of the
following occur:
• Your continuation premium is not paid on time.
• You become covered under another group health plan that does not exclude or limit treatment for
your pre-existing conditions.
• You become entitled to Medicare benefits.
• Your Plan Sponsor discontinues its health plan and no longer offers a group health plan to any of
its employees.
• Your continuation period was extended from 18 to 29 months due to disability, and you are no
longer considered disabled.
SingleSource Self-Insured 28
Exhibit B'
Type of Coverage
Under COBRA, you may continue any coverage you had before the qualifying event. If your Plan
Sponsor provides both medical and dental coverage and you were enrolled in both, you may continue
both medical and dental. If your Plan Sponsor provides only one type of coverage, or if you were
enrolled in only one type of coverage, you may continue only that coverage.
COBRA continuation benefits are always the same as your Plan Sponsor's current benefits. Your Plan
Sponsor has the right to change the benefits of its health plan or eliminate the plan entirely. If that
happens, any changes to the group health plan will also apply to everyone enrolled in continuation
coverage.
Your Responsibilities and Deadlines
You must notify your Plan Sponsor within 60 days if you divorce, or if your child no longer qualifies as
a dependent. That will allow your Plan Sponsor to notify you or your dependents of your continuation
rights.
When your Plan Sponsor learns of your eligibility for continuation, your Plan Sponsor will notify you of
your continuation rights and provide a Continuation Election Form. You then have 60 days from that
date or 60 days from the date coverage would otherwise end, whichever is later, to enroll in
continuation coverage by submitting a completed Election Form to your Plan Sponsor. If continuation
coverage is not elected during that 60-day period, coverage will end on the last day of the last month
you were an active employee.
If you do not provide these notifications within the time frames required by COBRA, Plan Sponsors
responsibility to provide coverage under the health plan will end.
Continuation Premium
You or your family members are responsible for the full cost of continuation coverage. The monthly
premium must be paid to your Plan Sponsor. PacificSource cannot accept continuation premium
directly from you. You may make your first premium payment any time within 45 days after you return
your Continuation Election Form to your Plan Sponsor. After the first premium payment, each monthly
payment must reach your Plan Sponsor within 30 days of your Plan Sponsors premium due date. If
your Plan Sponsor does not receive your continuation premium on time, continuation coverage will end.
If your coverage is canceled due to a missed payment, it will not be reinstated for any reason. Premium
rates are established annually and may be adjusted if the plan's benefits or costs change.
Keep Your Plan informed of Address Changes
In order to protect your and your family's rights, you should keep the Plan Sponsor informed of any
changes in your address and the addresses of family members. You should also keep a copy, for your
records, of any notices you send to the Plan Sponsor.
CONTINUATION WHEN YOU RETIRE
If you retire, you and your insured dependents are eligible to continue coverage subject to the following:
• You must apply for continued coverage within 60 days after retirement.
• You must be receiving benefits from PERS (Public Employee Retirement System) or from a similar
retirement plan offered by your Plan Sponsor.
• You will have the same opportunity to switch to another plan during the open enrollment period as
do active employees. If the plan's benefits are changed by the policyholder, your benefits will
change accordingly.
• Except for newly acquired dependents due to marriage, registration of domestic partnership, birth,
or adoption, only your dependents who were covered at the time of retirement may continue
coverage under this provision. You may add a new spouse, domestic partner, or other newly
acquired dependent after retirement if family coverage is available. A completed enrollment
application must be submitted within 31 days of the date of marriage, registration of domestic
partnership, birth, or adoption.
SingleSoufce Self-Insured 29
Exhibit'B'
Your continuation coverage will end when any one of the following occurs:
• When full premium is not paid or when your coverage is voluntarily terminated, your coverage will
end on the last day of the month for which premium was paid.
• When you become eligible for Medicare coverage, your coverage will end on the last day of the
month preceding Medicare eligibility.
• When the regular group policy is terminated, your coverage will end on the date of termination.
Your dependent's continuation coverage will end when any one of the following occurs:
• When full premium for the dependent is not paid or when the dependent's coverage is voluntarily
terminated by you or your dependent, coverage will end on the last day of the month for which
premium was paid.
• When your dependent becomes eligible for Medicare coverage, your dependent's coverage will end
on the last day of the month preceding Medicare eligibility.
• When you die, divorce, or dissolve your domestic partnership, your dependent's coverage will end
on the last day of the month following the death, divorce, or dissolution of the domestic partnership.
• When your dependent is otherwise no longer considered a dependent under the group plan, his or
her coverage will end on the last day of the month of their eligibility. Continuation of coverage may
be available under COBRA continuation (see Continuation of Coverage provisions).
• When the regular group policy is terminated, your dependent's coverage will end on the date of
termination.
WORK STOPPAGE
Labor Unions
If you are a union member, you have certain continuation rights in the event of a labor strike. Your
union is responsible for collecting your premium and can answer questions about coverage during the
strike.
EXTENSION OF BENEFITS
If you are on a Plan Sponsor-approved non-FMLA leave of absence, you may continue coverage under
active status for up to three months by self pay to the Plan Sponsor. Absences extending beyond three
months will be subject to the Continuation of Insurance provisions of this plan.
COVERED EXPENSES
This plan provides comprehensive medical coverage when care is medically necessary to treat an
illness or injury. Be careful -just because a treatment is prescribed by a healthcare professional does
not mean it is medically necessary under the terms of the plan. Also remember that just because a
service or supply is a covered benefit under this plan does not necessarily mean all billed charges will
be paid.
Some medically necessary services and supplies may be excluded from coverage under this plan. Be
sure you read and understand the Benefit Limitations and Exclusions section of this book, including the
section on Preauthorization. If you ever have a question about your plan benefits, contact the
PacificSource Customer Service Department.
Medical Necessity
Except for specified Preventive Care services, the benefits of this health plan are paid only toward the
covered expense of medically necessary diagnosis or treatment of illness or injury. This is true even
though the service or supply is not specifically excluded. All treatment is subject to review for medical
necessity. Review of treatment may involve prior approval, concurrent review of the continuation of
treatment, post-treatment review or any combination of these. For additional information, see 'medically
necessary' in the Definitions section of this Summary Plan Description.
SingleSource Self-Insured 30
Exhibit'B'
Be careful. Your healthcare provider could prescribe services or supplies that are not covered under
this plan. Also, just because a service or supply is a covered benefit does not mean all related charges
will be paid.
Healthcare Providers
This plan provides benefits only for covered expenses and supplies rendered a physician (M.D. or
O.D.), practitioner, nurse, hospital or specialized treatment facility, durable medical equipment supplier,
or other licensed medical provider as specifically stated in this Summary Plan Description. The services
or supplies provided by individuals or companies that are not specified as eligible practitioners are not
eligible for reimbursement under the benefits of this plan. For additional information, see 'practitioner',
'specialized treatment facility', and 'durable medical equipment supplier' in the Definitions section of this
Summary Plan Description.
Your Annual Deductible
Deductible Carryover. The deductible must be satisfied only once in any benefit year, even though
there may be several conditions treated. Covered expenses incurred during the last three (3) months of
the previous benefit year will be applied to the subsequent year's benefit year deductible subject to the
following:
• The covered expenses were applied to the deductible;
• The covered expenses were incurred during the last three (3) months of the year; and
• The prior year's deductible was not satisfied.
Final determination of which expenses apply to the deductible will be based on the order in which
charges are incurred, even if bills for charges are not received in that order.
Your Annual Out-of-Pocket Limit
This plan has an out-of-pocket limit provision to protect you from excessive medical expenses. The
Medical Benefit Summary shows your plan's annual out-of-pocket limits for participating and/or
nonparticipating providers. If you incur covered expenses over those amounts, this plan will pay 100
percent of eligible charges, subject to the allowable fee.
Your expenses for the following do not count toward the annual out-of-pocket limit:
• Charges applied to deductible, if applicable to your plan
• Co-payments, if applicable to your plan
• Prescription drugs
• Charges over the allowable fee for services of non-participating providers
• Incurred charges that exceed amounts allowed under this plan
Charges over the allowable fee for services of non-participating providers, and incurred charges that
exceed amounts allowed under this plan, and co-payments will continue to be your responsibility even
after the out-of-pocket or stop-loss limit is reached.
Prescription drug benefits are not affected by the out-of-pocket or stop-loss limit. You will still be
responsible for that co-payment or co-insurance payment even after the out-of-pocket or stop-loss limit
is reached.
MEDICAL BENEFITS
About Your Medical Benefits
All benefits provided under this plan must satisfy some basic conditions. The following conditions are
commonly included in health benefit plans but are often overlooked or misunderstood.
SingleSource Self-Insured 31
Exhibit'B'
Medical Necessity - The plan provides benefits only for covered services and supplies that are
medically necessary for the treatment of a covered illness or injury. Be careful just because a
treatment is prescribed by a healthcare professional does not necessarily mean it is medically
necessary as defined by the plan. And, some medically necessary services and supplies may be
excluded from coverage. Also, the treatment must not be experimental and/or investigational.
Allowable Fees - The plan provides benefits only for covered expenses that are equal to or less than
the allowable amount, as defined by the plan, in the geographic area where services or supplies are
provided. Any amounts that exceed the allowable amount are not recognized by the plan for any
purpose.
Health Care Provider - The plan provides benefits only for covered expenses and supplies rendered
by a physician, practitioner, nurse, hospital or specialized treatment facility, durable medical equipment
supplier, or other licensed medical provider as specifically stated in this plan summary. The services or
supplies provided by individuals or companies that are not specified as eligible practitioners are not
eligible for reimbursement under the benefits of this plan. For additional information, see practitioner,
specialized treatment facility, and durable medical equipment in the Definitions section of this
document.
Custodial Care Providers - The plan does not provide benefits for services and supplies that are
furnished primarily to assist an individual in the activities of daily living. Activities of daily living include
such things as bathing, feeding, administration of oral medications, academic, social, or behavior skills
training, and other services that can be provided by persons without the training of a health care
practitioner.
Benefit Year - The word year, as used in this document, refers to the benefit year, which is the 12-
month period beginning January 1 and ending December 31. Unless otherwise specified, all annual
benefit maximums and deductibles accumulate during the benefit year.
Deductibles - A deductible is the amount of covered expenses you must pay during each year before
the plan will consider expenses for reimbursement. The individual deductible applies separately to each
covered person. The family deductible applies collectively to all covered persons in the same family.
When the family deductible is satisfied, no further deductible will be applied for any covered family
member during the remainder of the year. The annual individual and family deductible amounts are
shown on the Medical Benefit Summary.
Benefit Percentage Payable - Benefit percentage payable represents the portion of covered
expenses paid by the plan after you have satisfied any applicable deductible. These percentages apply
only to covered expenses which do not exceed the allowable amount. You are responsible for all
remaining covered and non-covered expenses, including any amount that exceeds the allowable
amount for covered services. The benefit percentages payable are shown on the Medical Benefit
Summary.
Copayments - Copayments are the first-dollar amounts you must pay for certain covered services,
which are usually paid at the time the service is performed (i.e. physician office visits or emergency
room visits). These copayments do not apply to your annual deductible or out-of-pocket maximum,
unless otherwise specified on the Medical Benefit Summary. The copayment amounts are shown on
the Medical Benefit Summary.
Out-Of-Pocket Maximum(s) - An out-of-pocket maximum is the maximum amount of covered
expenses you must pay during a year, before the plan's benefit percentage payable increases. The
individual out-of-pocket maximum applies separately to each covered person. When a covered person
reaches the annual out-of-pocket maximum, the plan will pay 100% of additional covered expenses for
that individual during the remainder of that year, subject to the lifetime maximum amount, if applicable.
However, expenses for services which do not apply to the out-of-pocket maximum will never be paid at
100%. The annual individual and family out-of-pocket maximum amounts are shown on the Medical
Benefit Summary.
Benefit Maximums - Total plan payments for each covered person are limited to certain maximum
benefit amounts. A benefit maximum can apply to specific benefit categories or to all benefits. A benefit
maximum amount may also apply to a specific time period, such as annual.
SingleSource Self-Insured 32
Exhibit 'B'
Least Costly Setting For Services - Benefits of the plan provide for reimbursement of covered
services performed in the least costly setting where services can be safely provided. If a procedure can
be done safely in an outpatient setting but is performed in a hospital inpatient setting, this plan will only
pay what it would have paid for the procedure on an outpatient basis. If services are performed in an
inappropriate setting, your benefits may be reduced.
PLAN BENEFITS
This plan provides benefits for the following services and supplies as outlined on your Medical Benefit
Summary. These services and supplies may require you to satisfy a deductible, make a co-payment, or
both, and they may be subject to additional limitations or maximum dollar amounts. For a medical
expense to be eligible for payment, you must be covered under this plan on the date the expense is
incurred. Please refer to your Medical Benefit Summary and the Benefit Limitations and Exclusions
section of this Summary Plan Description for more information.
Accident Benefit
In the event of an injury caused by an accident the plan benefit will be as follows:
The balance is covered as stated in your Medical Benefit Summary for covered expense.
'Accident' means an unforeseen or unexpected event causing injury which requires medical attention.
'Injury' means bodily trauma or damages which is independent of disease or infirmity. The damage
must be caused solely through external and accidental means. For the purpose of this benefit, injury
does not include musculoskeletal sprains or strains obtained in the performance of physical activity.
PREVENTIVE CARE SERVICES
This plan covers the following preventive care services when provided by a physician, physician
assistant, or nurse practitioner:
• Routine physicals for members age 22 and older according to the following schedule:
Ages 22 and over One exam every benefit year
Only laboratory work tests and other diagnostic testing procedures related to the routine physical
exam are covered by this benefit. Any laboratory tests and other diagnostic testing procedures
ordered during, but not related to, a routine physical examination are not covered by this
preventative care benefit. Please see Outpatient Services in this section.
• Well woman visits, including the following:
- One routine gynecological exam each benefit year for women 18 and over. Exams may
include Pap smear, pelvic exam, breast exam, blood pressure check, and weight check. Exams
may also include an annual mammogram for women over the age of 40, once between the
ages of 35-40 unless medically necessary, for the purpose of early detection. Covered lab
services are limited to occult blood, urinalysis, and complete blood count.
- Routine preventive mammograms for women as recommended.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Preventive Care - Well Woman Visits' applies.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Outpatient Services - Diagnostic and Therapeutic Radiology and Lab'
applies to diagnostic mammograms related to the ongoing evaluation or treatment of a
medical condition.
Pelvic exams and Pap smear exams at any time upon referral of a women's healthcare
provider; and pelvic exams and Pap smear exams annually for women 18 to 64 years of age
with or without a referral from a women's healthcare provider.
- Breast exams annually for women 18 years of age or older or at any time when recommended
by a women's healthcare provider for the purpose of checking for lumps and other changes for
early detection and prevention of breast cancer.
• Colorectal cancer screening exams and lab work including the following:
SingleSource Self-Insured 33
Exhibit'&
A fecal occult blood test once per benefit year
A flexible sigmoidoscopy every five benefit years
A colonoscopy for age 50+ every ten benefit years
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for'Preventive Care - Routine Colonoscopy' applies.
o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit
Summary for 'Professional Services - Surgery' and for'Outpatient Services -
Outpatient Surgery/Services' apply to colonoscopies'related to ongoing evaluation or
treatment of a medical condition.
A double contrast barium enema every five benefit years
• Prostate cancer screening, every two benefit years. Exams may include a digital rectal
examination and a prostate-specific antigen test. Screenings apply to outpatient surgery/services
benefit regardless of whether they are preventive or diagnostic.
• Well baby/well child care exams for members age 21 and younger according to the following
schedule:
At birth: One standard in-hospital exam
Ages 0 - 2: 12 additional exams during first 36 months of life- Ages 3 - 21:
One exam per benefit year
Newborn circumcision is a covered benefit even if performed several days after birth. Only
laboratory tests and other diagnostic testing procedures related to a well baby/child care exam are
covered by this plan. Any laboratory tests and other diagnostic testing procedures ordered during,
but not related to, a well baby/child care exam are not covered by this preventative care benefit.
Please see Outpatient Services in this section.
• Standard age-appropriated childhood and adult immunizations for primary prevention of infectious
diseases as recommended by and adopted the Centers for Disease Control and Prevention,
American Academy of Pediatrics, American Academy of Family Physicians, or similar standard-
setting body. Benefits do not include immunizations for more elective, investigative, unproven, or
discretionary reasons (e.g. travel). Covered immunizations include, but may not be limited to the
following:
- Diphtheria, pertussis, and tetanus (DPT) vaccines, given separately or together
- Hemophilus influenza B vaccine
Hepatitis A vaccine
- Hepatitis B vaccine
- Human papillomavirus (HPV) vaccine
Influenza vaccine
- Measles, mumps, and rubella (MMR) vaccines, given separately or together
- Meningococcal (meningitis) vaccine
- Pneumococcal vaccine
- Polio vaccine
Varicella (chicken pox) vaccine
• Tobacco use cessation program services are covered only when provided by a PacificSource
approved program. Approved programs are covered at 100% of the cost up to a maximum lifetime,,
benefit of two quit attempts. Approved programs are limited to members age 15 or older. Specific
nicotine replacement therapy will only be covered according to the program's description. If this
policy includes benefits for prescription drugs, tobacco use cessation related medication prescribed
in conjunction with an approved tobacco use cessation program will be covered to the same extent
this policy covers other prescription medications.
PROFESSIONAL SERVICES
This plan covers the following professional services when medically necessary:
SingleSource Self-Insured 34
Exhibit'&
• Services of a physician (M.D. or D.O.) for diagnosis or treatment of illness or injury
• Services of a licensed physician assistant under the supervision of a physician
• Services of a certified surgical assistant, surgical technician, or registered nurse (R.N.) when
providing medically necessary services as a surgical first assistant during a covered surgery
• Services of a nurse practitioner, including certified registered nurse anesthetist (C.R.N.A.) and
certified nurse midwife (C.N.M.), for medically necessary diagnosis or treatment of illness or injury
• Urgent care services provided by a physician. Urgent care is unscheduled medical care for an
illness, injury, or disease that a prudent lay person would consider not life-threatening and treatable
at urgent care. Examples of urgent care situations include sprains, cuts, and illnesses that do not
require immediate medical attention in order to prevent seriously damaging the health of the
person.
• Outpatient rehabilitative services provided by a licensed physical therapist, occupational
therapist, speech language pathologist, physician, or other practitioner licensed to provide physical,
occupational, or speech therapy. Services must be prescribed in writing by a licensed physician,
dentist, podiatrist, nurse practitioner, or physician assistant. The prescription must include site,
modality, duration, and frequency of treatment. Total covered expenses for outpatient rehabilitative
services is limited to a combined maximum of 30 visits per benefit year subject to preauthorization
and concurrent review by PacificSource for medical necessity. Only treatment of neurologic
conditions (e.g. stroke, spinal cord injury, head injury, pediatric neurodevelopmental problems, and
other problems associated with pervasive developmental disorders for which rehabilitative services
would be appropriate for children under 18 years of age) may be considered for additional benefits,
not to exceed 30 visits per condition, when criteria for supplemental services are met.
• Services for speech therapy will only be allowed when needed to correct stuttering, hearing loss,
peripheral speech mechanism problems, and deficits due to neurological disease or injury. Speech
and/or cognitive therapy for acute illnesses and injuries are covered up to one year post injury
when the services do not duplicate those provided by other eligible providers, including
occupational therapists or neuropsychologists.
• Outpatient pulmonary rehabilitation programs are covered when prescribed by a physician for
patients with severe chronic lung disease that interferes with normal daily activities despite optimal
medication management.
• For related provisions, see 'motion analysis', 'vocational rehabilitation', and 'speech therapy' under
'Excluded Services - Types of Treatments' in the Benefit Limitations and Exclusions section of this
Summary Plan Description.
• Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to
the same payment amounts, conditions, and limitations that apply to similar expenses for illness,
except that pregnancy is not considered a pre-existing condition.
Please contact the PacificSource Customer Service Department as soon as you learn of your
pregnancy. PacificSource's staff will explain your plan's maternity benefits and help you enroll in
PacificSource's free prenatal care program.
• Routine nursery care of a newborn while the mother is hospitalized and eligible for pregnancy-
related benefits under this plan if the newborn is also eligible and enrolled in this plan.
• Services of a licensed audiologist for medically necessary audiological (hearing) tests.
• Services of a dentist or physician to treat injury of the jaw or natural teeth. Services must be
provided within 18 months of the injury. Except for the initial examination, services for treatment of
an injury to the jaw or natural teeth require preauthorization to be covered.
• Services of a dentist or physician for orthognathic (jaw) surgery as follows:
- When medically necessary to repair an accidental injury. Services must be provided within
one year after the accident.
- For removal of a malignancy, including reconstruction of the jaw within one year after that
surgery
• Services of a board-certified or board-eligible genetic counselor when referred by a physician or
nurse practitioner for evaluation of genetic disease
SingleSource Self-Insured 35
Exhibit'B'
• Medically necessary telemedical health services for health services covered by this plan when
provided in person by a healthcare professional when the telemedical health service does not
duplicate or supplant a health service that is available to the patient in person. The location of the
patient receiving telemedical health services may include, but is not limited to: hospital; rural health
clinic; federally qualified health center, physician's office; community mental health center; skilled
nursing facility; renal dialysis center; or site where public health services are provided. Coverage of
telemedical health services are subject to the same deductible, co-payment, or co-insurance
requirements that apply to comparable health services provided in person.
HOSPITAL AND SKILLED NURSING FACILITY SERVICES
This plan covers medically necessary hospital inpatient services. Charges for a hospital room are
covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer
semi-private rooms). Charges for a private room are covered if the attending physician orders
hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary
isolation. Coverage includes eligible services provided by a hospital owned or operated by the state of
Oregon, or any state approved mental health and developmental disabilities program.
In addition to the hospital room, covered inpatient hospital services may include (but are not limited to):
• Cardiac care unit
• Operating room
• Anesthesia and post-anesthesia recovery
• Respiratory care
• Inpatient medications
• Lab and radiology services
• Dressings, equipment, and other necessary supplies
The plan does not cover charges for rental of telephones, radios, or televisions, or for guest meals,or
other personal items.
Services of a skilled nursing facility and convalescent homes are covered for up to 120 days per
benefit year when preauthorized by PacificSource. Services must be medically necessary. Confinement
for custodial care is not covered.
Inpatient rehabilitative services are covered up to a maximum of 50 days of rehabilitative care per
benefit year, except that treatment for head or spinal cord injuries is covered for up to 60 days per
benefit year. Recreation therapy is only covered as part of an inpatient rehabilitation admission.
Services must be preauthorized by PacificSource
OUTPATIENT SERVICES
This plan covers the following outpatient care services:
• Advanced diagnostic imaging procedures that are medically necessary for the diagnosis of
illness or injury. For purposes of this benefit, advanced diagnostic imaging procedures include CT
scans, MRIs, PET scans, CATH labs and nuclear cardiology studies. When services are provided
as part of a covered emergency room visit, your plan's emergency room benefit applies. In all other
situations and settings, benefits are subject to the deductibles, co-payments, and/or co-insurance
stated in your Medical Benefit Summary for Outpatient Services - Advanced Diagnostic Imaging.
• Diagnostic radiology and laboratory procedures provided or ordered by a physician, nurse
practitioner, or physician assistant. These services may be performed or provided by laboratories,
radiology facilities, hospitals, and physicians, including services in conjunction with office visits.
SingleSource Self-Insured 36
Exhibit H
• Benefits for members who are receiving services for end-stage renal disease (ESRD) who are
eligible for Medicare, are limited to 125% of the current Medicare allowable amount for participating
and nonparticipating ESRD service providers. Benefits will continue to be paid at the cost share
level applied to other benefits in the same category for members who are not eligible for Medicare.
PacificSource will contact members when the first ESRD preauthorization request is received to
assist the member in understanding their out-of-pocket expenses and care plan.
• Emergency room services. The emergency room co-payment stated in your Medical Benefit
Summary covers medical screening and any diagnostic tests needed for emergency care, such as
radiology, laboratory work, CT scans, and MRIs. The co-payment does not cover further treatment
provided on referral from the emergency room.
In true medical emergencies, non-participating providers are paid at the participating provider level.
Emergency room charges for services, supplies, or conditions excluded from coverage under this
plan are not eligible for payment. That includes conditions subject to the plan's exclusion periods
for pre-existing and other conditions. Please see the Benefit Limitations and Exclusions section of
this Summary Plan Description.
• Surgery and other outpatient services. Benefits are based on the setting where services are
performed.
- For surgeries or outpatient services performed in a physician's office, the benefit stated in
your Medical Benefit Summary for Professional Services - Office Procedures and Supplies
applies.
- For surgeries or outpatient services performed in an ambulatory surgical center or
outpatient hospital setting, both the benefits stated in your Medical Benefit Summary for
Professional Services - Surgery and the Outpatient Services -Outpatient Surgery/Services
apply.
• Therapeutic radiology services, chemotherapy, and renal dialysis provided or ordered by a
physician. Covered services include a prescribed, orally administered anticancer medication used
to kill or slow the growth of cancerous cells.
• Other medically necessary diagnostic services provided in a hospital or outpatient setting,
including testing or observation to diagnose the extent of a medical condition.
EMERGENCY SERVICES
In a true medical emergency, this plan covers services and supplies necessary to determine the nature
and extent of the emergency condition and to stabilize the patient.
An emergency medical condition is an injury or sudden illness, including severe pain, so severe that a
prudent layperson with an average knowledge of health and medicine would expect that failure to
receive immediate medical attention would risk seriously damaging the health of a person or fetus in the
case of a pregnant woman. Examples of emergency medical conditions include (but are not limited to):
• Unusual or heavy bleeding
• Sudden abdominal or chest pains
• Suspected heart attacks
• Major traumatic injuries
• Serious burns
• Poisoning
• Unconsciousness
• Convulsions or seizures
• Difficulty breathing
• Sudden fevers
SingleSource Self-Insured 37
Exhibit 'B'
If you need immediate assistance for a medical emergency, call 911. If you have an emergency
medical condition, you should go directly to the nearest emergency room or appropriate facility. Care
for a medical emergency is covered at the participating provider percentage stated in your Medical
Benefit Summary even if you are treated at a non-participating hospital.
If you are admitted to a non-participating hospital after your emergency condition is stabilized, your Plan
Sponsor may require you to transfer to a participating facility in order to continue receiving benefits at
the participating provider level.
Maternity Services
Maternity means, in any one pregnancy, all prenatal services including complications and miscarriage,
delivery, postnatal services provided within six months of delivery, and routine nursery care of a
newborn child. Maternity services are covered subject to the deductible, co-payments, and/or co-
insurance stated in your Medical Benefit Summary regardless of marital status.
• Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to
the same payment amounts, conditions, and limitations that apply to similar expenses for illness.
• Please contact the PacificSource Customer Service Department as soon as you learn of your
pregnancy. PacificSource's staff will explain your plan's maternity benefits and help you enroll in
PacificSource's free prenatal care program.
• This plan provides routine nursery care of a newborn while the mother is hospitalized and eligible
for pregnancy-related benefits under this plan if the newborn is also eligible and enrolled in this
plan, regardless of marital status.
Special Information about Childbirth - This plan covers hospital inpatient services for childbirth
according to the Newborns' and Mothers' Health Protection Act of 1996. This plan does not restrict the
length of stay for the mother or newborn child to less than 48 hours after vaginal delivery, or to less
than 96 hours after Cesarean section delivery. Your provider is allowed to discharge you or your
newborn sooner than that, but only if you both agree. For childbirth, your provider does not need to
preauthorize your hospital stay with PacificSource.
MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES
This plan covers medically necessary crisis intervention, diagnosis, and treatment of mental health
conditions and chemical dependency. Refer to the Benefit Limitations and Exclusions section of this
Summary Plan Description for more information on services not covered by your plan.
Mental Health and Chemical Dependency Services
It is the intent of this plan to comply with all existing regulations of Mental Health Parity and Addiction
Equity Act of 2008 (MHPAEA). If for some reason the information presented in the plan differs from the
actual regulations of the MHPAEA, the plan reserves the right to administer the plan in accordance with
such actual regulations.
Providers Eligible for Reimbursement
A mental and/or chemical healthcare provider (see Definitions section of this Summary Plan
Description) is eligible for reimbursement if:
• The mental and/or chemical healthcare provider is approved by the Oregon Department of Human
Services,
• The mental and/or chemical healthcare provider is accredited for the particular level of care for
which reimbursement is being requested by the Oregon Joint Commission on Accreditation of
Hospitals or the Commission on Accreditation of Rehabilitation Facilities; or
• The patient is staying overnight at the mental and/or chemical healthcare facility (see Definitions
section of this Summary Plan Description) and is involved in a structured program at least eight
hours per day, five days per week; or
• The mental and/or chemical healthcare provider is providing a covered benefit under this policy;
and
SingleSource Self-Insured 38
Exhibit'B'
Eligible mental and/or chemical healthcare providers are:
• A program licensed, approved, established, maintained, contracted with, or operated by the
Addictions and Mental Health Division of the Oregon Health Authority;
• A medical or osteopathic physician licensed by the State Board of Medical Examiners,
• A psychologist (Ph.D.) licensed by the State Board of Psychologists' Examiners;
• A nurse practitioner registered by the State Board of Nursing;
• A clinical social worker (L.C.S.W.) licensed by the State Board of Clinical Social Workers;
• A Licensed Professional Counselor (L.P.C) licensed by the State Board of Licensed Professional
Counselors and Therapists;
• A Licensed Marriage and Family Therapist (L.M.F.T) licensed by the State Board of Licensed
Professional Counselors and Therapists; and
• A hospital or other healthcare facility licensed by the Joint Commission on Accreditation of
Hospitals or the Commission on Accreditation of Rehabilitation Facilities for inpatient or residential
care and treatment of mental health conditions and/or chemical dependency.
Medical Necessity and Appropriateness of Treatment
As with all medical treatment, mental health and chemical dependency treatment is subject to
review for medical necessity and/or appropriateness. Review of treatment may involve pre-service
review, concurrent review of the continuation of treatment, post-treatment review, or a combination
of these. PacificSource will notify the patient and patient's provider when a treatment review is
necessary to make a determination of medical necessity.
• A second opinion may be required for a medical necessity determination. PacificSource will notify
the patient when this requirement is applicable.
• PacificSource must be notified of an emergency admission within two business days.
• Medication management by an M.D. (such as a psychiatrist) does not require review.
• Treatment of substance abuse and related disorders is subject to placement criteria established by
the American Society of Addiction Medicine.
Mental Health Parity and Addiction Equity Act of 2008
This group health plan complies with all federal laws and regulations related to the Mental Health Parity
and Addiction Equity Act of 2008.
HOME HEALTH AND HOSPICE SERVICES
• This plan covers home health services up to 180 visits per benefit year when preauthorized by
PacificSource. Covered services include skilled nursing by a R.N. or L.P.N.; physical, occupational,
and speech therapy, and medical social work services provided by a licensed home health agency.
Private duty nursing is not covered.
• Home infusion services are covered when preauthorized by PacificSource. This benefit covers
parenteral nutrition, medications, and biologicals (other than immunizations) that cannot be self-
administered. Benefits are paid at the percentage stated in your Medical Benefit Summary for home
health care.
• This plan covers hospice services when preauthorized by PacificSource. Hospice services are
intended to meet the physical, emotional, and spiritual needs of the patient and family during the
final stages of illness and dying, while maintaining the patient in the home setting. Services are
intended to supplement the efforts of an unpaid caregiver. Hospice benefits do not cover services
of a primary caregiver such as a relative or friend, or private duty nursing. PacificSource uses the
following criteria to determine eligibility for hospice benefits:
- The member's physician must certify that the member is terminally ill with a life expectancy of
less than six months;
- The member must be living at home;
- A non-salaried primary caregiver must be available and willing to provide custodial care to the
member on a daily basis; and
SingleSource Self-Insured 39
Exhibit'B'
- The member must not be undergoing treatment of the terminal illness other than for direct
control of adverse symptoms.
Only the following hospice services are covered:
- Home nursing visits.
- Home health aides when necessary to assist in personal care.
- Home visits by a medical social worker.
- Home visits by the hospice physician.
- Prescription medications for the relief of symptoms manifested by the terminal illness.
- Medically necessary physical, occupational, and speech therapy provided in the home.
- Home infusion therapy.
- Durable medical equipment, oxygen, and medical supplies.
- Respite care provided in a nursing facility to provide relief for the primary caregiver, subject to a
maximum of five consecutive days and to a lifetime maximum benefit of 30 days. A member
must be enrolled in a hospice program to be eligible for respite care benefits.
- Inpatient hospice care when provided by a Medicare-certified or state-certified program when
admission to an acute care hospital would otherwise be medically necessary.
- Pastoral care and bereavement services.
The member retains the right to all other services provided under this contract, including active
treatment of non-terminal illnesses, except for services of another provider that duplicate the services of
the hospice team.
DURABLE MEDICAL EQUIPMENT
• This plan covers prosthetic and orthotic devices that are medically necessary to restore or
maintain the ability to complete activities of daily living or essential job-related activities and that are
not solely for comfort or convenience. Benefits include coverage of all services and supplies
medically necessary for the effective use of a prosthetic or orthotic device, including formulating its
design, fabrication, material and component selection, measurements, fittings, static and dynamic
alignments, and instructing the patient in the use of the device. Benefits also include coverage for
any repair or replacement of a prosthetic or orthotic device that is determined medically necessary
to restore or maintain the ability to complete activities of daily living or essential job-related activities
and that is not solely for comfort or convenience.
• This plan covers durable medical equipment prescribed exclusively to treat medical conditions.
Covered equipment includes crutches, wheelchairs, orthopedic braces, home glucose meters,
equipment for administering oxygen, and non-power assisted prosthetic limbs and eyes. Durable
medical equipment must be prescribed by a licensed M.D., D.O., N.P., P.A., D.D.S., D.M.D., or
D.P.M. to be covered. This plan does not cover equipment commonly used for nonmedical
purposes, for physical or occupational therapy, or prescribed primarily for comfort. Please see
'Excluded Services - Equipment and Devices' in the Benefit Limitations and Exclusions section for
information on items not covered. The following limitations apply to durable medical equipment:
- This benefit covers the cost of either purchase or rental of the equipment for the period
needed, whichever is less. Repair or replacement of equipment is also covered when
necessary, subject to all conditions and limitations of the plan. If the cost of the purchase,
rental, repair, or replacement is over $800, preauthorization by PacificSource is required.
- Only expenses for durable medical equipment, or prosthetic and orthotic devices that are
provided by a PacificSource contracted provider or a provider that satisfies the criteria of
the Medicare fee schedule for Suppliers of Durable Medical Equipment, Prosthetics,
Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description
are eligible for reimbursement. Mail order or InternettWeb based providers are not eligible
providers.
- Purchase, rental, repair, lease, or replacement of a power-assisted wheelchair (including
batteries and other accessories) requires preauthorization by PacificSource and is payable
only in lieu of benefits for a manual wheelchair.
SingleSource Self-Insured 40
Exhibit'B'
The durable medical equipment benefit also covers lenses to correct a specific vision
defect resulting from a severe medical or surgical problem, such as stroke, neurological
disease, trauma, or eye surgery other than refraction procedures. Coverage is subject to
the following limitations:
o The medical or surgical problem must cause visual impairment or disability due to loss
of binocular vision or visual field defects (not merely a refractive error or astigmatism)
that requires lenses to restore some normalcy to vision.
o The maximum allowance for glasses (lenses and frames), or contact lenses in lieu of
glasses, is limited to $200 per initial case. 'Initial case' is defined as the first time
surgery or treatment is performed on either eye. Other policy limitations, such as
exclusions for extra lenses, other hardware, tinting of lenses, eye exercises, or vision
therapy, also apply.
o Benefits for subsequent medically necessary vision corrections to either eye (including
an eye not previously treated) are limited to the cost of lenses only.
Reimbursement is subject to the deductible, co-payment, and/or co-insurance stated in
your Medical Benefit Summary for durable medical equipment and is in lieu of, and not in
addition to benefits payable under any vision endorsement that may be added to this plan.
The durable medical equipment benefit also covers hearing aids for members under 18
years of age and younger, or 25 years of age and younger if the member is enrolled in a
secondary school or an accredited educational institution. Coverage is limited to a
maximum benefit of $4,000 every 48 months. The benefit amount may be adjusted on
January 1 of each year to reflect the U.S City Average Consumer Price Index.
Medically necessary treatment for sleep apnea and other sleeping disorders is covered
when preauthorized by PacificSource. Coverage of oral devices includes charges for
consultation, fitting, adjustment, follow-up care, and the appliances , is limited to a lifetime
maximum benefit of $500, including charges for consultation, fitting, adjustment, follow-up
care, and the appliance.. The appliance must be prescribed by a physician specializing in
evaluation and treatment of obstructive sleep apnea, and the condition must meet criteria
for obstructive sleep apnea.
Wigs following chemotherapy or radiation therapy are covered up to a maximum benefit of
$150 per benefit year.
Breastfeeding pumps, manual and electric, are covered at no cost per pregnancy when
purchased or rented from a licensed provider, or purchased from a retail outlet. Hospital-
grade breast pumps are excluded under preventive care and regular benefits.
TRANSPLANT SERVICES
This plan covers certain medically necessary organ and tissue transplants. It also covers the cost of
acquiring organs or tissues needed for covered transplants and limited travel expenses for the patient,
subject to certain limitations.
All pretransplant evaluations, services, treatments, and supplies for transplant procedures require
preauthorization by PacificSource.
You must have been covered under this plan for at least 24 consecutive months or since birth to be
eligible for transplant benefits, including benefits for transplantation evaluation. See Exclusion Periods -
Transplants in the Benefit Limitations and Exclusions section of this Summary Plan Description for
details.
This plan covers the following medically necessary organ and tissue transplants:
• Kidney
• Kidney - Pancreas
• Pancreas whole organ transplantation (under certain criteria)
• Heart
• Heart - Lung
SingleSource Self-Insured 41
Exhibit'B'
• Lung
• Liver (under certain criteria)
• Bone marrow and peripheral blood stem cell
• Pediatric bowel
This plan only covers transplants of human body organs and tissues. Transplants of artificial, animal, or
other non-human organs and tissues are not covered.
Expenses for the acquisition of organs or tissues for transplantation are covered only when the
transplantation itself is covered under this contract, and is subject to the following limitations:
• Testing of related or unrelated donors for a potential living related organ donation is payable at the
same percentage that would apply to the same testing of an insured recipient.
• Expense for acquisition of cadaver organs is covered, payable at the same percentage and subject
to the same maximum dollar limitation, if any, as the transplant itself.
• Medical services required for the removal and transportation of organs or tissues from living donors
are covered. Coverage of the organ or tissue donation is at the same percentage payable for the
transplant itself up to $8,000 if the donor is a member of this plan, and applies to the maximum
dollar limitation for the transplant, if any.
- If the donor is not a PacificSource member, only those complications of the donation that occur
during the initial hospitalization are covered, and such complications are covered only to the
extent that they are not covered by another health plan or government program. Coverage is at
the same percentage payable for the transplant itself, and also applies to the maximum dollar
limitation, if any, for the transplant.
- If the donor is a PacificSource member, complications of the donation are covered as any other
illness would be covered.
• Transplant related services, including HLA typing, sibling tissue typing, and evaluation costs, are
considered transplant expenses and accumulate toward any transplant benefit limitations and are
subject to PacificSource's provider contractual agreements (see Payment of Transplant Benefits,
below).
Travel and housing expenses for the recipient are limited to $5,000 per transplant. Travel and living
expenses are not covered for the donor.
Payment of Transplant Benefits
If a transplant is performed at a participating Center of Excellence transplantation facility, covered
charges of the facility are subject to plan deductibles (co-insurance and co-payment amounts after
deductible are waived). If PacificSource's contract with the facility includes the services of the medical
professionals performing the transplant (such as physicians, nurses, and anesthesiologists), those
charges are also subject to plan deductibles (co-insurance and co-payment amounts after deductible
are waived). If the professional fees are not included in PacificSource's contract with the facility, then
those benefits are provided according to your Medical Benefit Summary.
If transplant services are available through a contracted transplantation facility but are not performed at
a contracted facility, you are responsible for satisfying any deductibles or co-payments stated in your
Medical Benefit Summary. This plan then pays at of 60% of the LICR after deductible and co-payments.
Services of non-participating medical professionals are paid at the non-participating provider benefit
level percentages and do not apply to the out-of-pocket maximum.
OTHER COVERED SERVICES, SUPPLIES, AND
TREATMENTS
• This plan covers services of a state certified ground or air ambulance when private transportation
is medically inappropriate because the acute medical condition requires paramedic support.
Benefits are provided for emergency ambulance service and/or transport to the nearest facility
capable of treating the condition. Air ambulance service is covered only when ground transportation
is medically or physically inappropriate. Reimbursement to nonparticipating air ambulance services
are based on 125% of the Medicare allowance. In some cases Medicare allowance may be
SingleSource Self-Insured 42
Exhibit'B'
significantly lower than the provider's billed amount. The provider may hold you responsible for the
amount they bill in excess of the Medicare allowance, as well as applicable deductibles and
coinsurance. Medically necessary travel, other than transportation by a licensed ambulance
service, to the nearest facility qualified to treat the patient's medical condition is covered when
approved in advance by PacificSource.
• This plan covers biofeedback to treat migraine headaches or urinary incontinence when provided
by an otherwise eligible practitioner.
• This plan covers blood transfusions, including the cost of blood or blood plasma.
• This plan covers removal, repair, or replacement of an internal breast prosthesis due to a
contracture or rupture, but only when the original prosthesis was for a medically necessary
mastectomy. Preauthorization by PacificSource is required, and eligibility for benefits is subject to
the following criteria:
- The contracture or rupture must be clinically evident by a physician's physical examination,
imaging studies, or findings at surgery.
- This plan covers removal, repair, and/or replacement of the prosthesis; a new reconstruction is
not covered.
- Removal, repair, and/or replacement of the prosthesis is not covered when recommended due
to an autoimmune disease, connective tissue disease, arthritis, allergenic syndrome,
psychiatric syndrome, fatigue, or other systemic signs or symptoms.
- PacificSource may require a signed loan receipt/subrogation agreement before providing
coverage for this benefit.
• This plan covers breast reconstruction in connection with a medically necessary mastectomy.
Coverage is provided in a manner determined in consultation with the attending physician and
patient for:
- All stages of reconstruction of the breast on which the mastectomy was performed;
- Surgery and reconstruction of the other breast to produce a symmetrical appearance;
- Prostheses; and
- Treatment of physical complications of the mastectomy, including lymphedema
Benefits for breast reconstruction are subject to all terms and provisions of the plan, including
deductibles, co-payments and/or co-insurance stated in your Medical Benefit Summary.
• This plan covers cardiac rehabilitation as follows:
- Phase I (inpatient) services are covered under inpatient hospital benefits.
- Phase II (short-term outpatient) services are covered subject to the deductible, co-payment,
and/or co-insurance stated in your Medical Benefit Summary for outpatient hospital
benefits. Benefits are limited to services provided in connection with a cardiac rehabilitation
exercise program that does not exceed 36 sessions and that are considered reasonable
and necessary.
- Phase III (long-term outpatient) services are not covered.
• This plan covers IUD, diaphragm, and cervical cap contraceptive devices along with their
insertion or removal. Contraceptive devices that can be obtained over the counter or without a
prescription, such as condoms are not covered.
• This plan covers corneal transplants. Preauthorization is not required.
• In the following situations, this plan covers one attempt at cosmetic or reconstructive surgery:
- When necessary to correct a functional disorder; or
- When necessary because of an accidental injury, or to correct a scar or defect that resulted
from treatment of an accidental injury; or
- When necessary to correct a scar or defect on the head or neck that resulted from a
covered surgery.
Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar,
or defect first occurred. Preauthorization by PacificSource is required for all cosmetic and
SingleSource Self-Insured 43
Exhibit 'B'
reconstructive surgeries covered by this plan. For information on breast reconstruction, see 'breast
prosthesis' and 'breast reconstruction' in this section.
• This plan covers dental and orthodontic services for the treatment of craniofacial anomalies when
medically necessary to restore function. Coverage includes but is not limited to physical disorders
identifiable at birth that affect the bony structures of the face or head, such as cleft palate, cleft lip,
craniosynostosis, craniofacial microsomia and Treacher Collins syndrome. Coverage is limited to
the least costly clinically appropriate treatment. Cosmetic procedures and procedures to improve on
the normal range of functions are not covered. See the exclusions for cosmetic/reconstructive
services, dental examinations and treatment, jaw surgery, and orthognathic surgery under the
'Excluded Services' section
• This plan provides coverage for certain diabetic supplies and training as follows:
- Diabetic supplies other than insulin and syringes (such as lancets, test strips, and glucostix)
are covered subject to the deductible, co-payment, and/or co-insurance stated in your
Medical Benefit Summary for durable medical equipment. You may purchase those
supplies from any retail outlet and send your receipts to PacificSource, along with your
name, group number, and member ID number. PacificSource will process the claim and
mail you a reimbursement check.
- Diabetic insulin and syringes are covered under your prescription drug benefit, if your plan
includes prescription coverage. Lancets and test strips are also available under that
prescription benefit in lieu of those covered supplies under the medical plan.
- This plan covers one diabetes self-management education program at the time of
diagnosis, and up to three hours of education per year if there is a significant change in
your condition or its treatment. To be covered, the training must be provided by an
accredited diabetes education program, or by a physician, registered nurse, nurse
practitioner, certified diabetes educator, or licensed dietitian with expertise in diabetes.
- This plan covers medically necessary telemedical health services provided in connection
with the treatment of diabetes (see Professional Services in this section).
• This plan covers dietary or nutritional counseling provided by a registered dietitian under certain
circumstances. It is covered under the diabetic education benefit, or for management of inborn
errors of metabolism (excluding obesity), or for management of anorexia nervosa or bulimia
nervosa (to a lifetime maximum of five visits).
• This plan covers nonprescription elemental enteral formula ordered by a physician for home use.
Formula is covered when medically necessary to treat severe intestinal malabsorption and the
formula comprises a predominant or essential source of nutrition. Coverage is subject to the
deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable
medical equipment.
• This plan covers routine foot care for patients with diabetes mellitus.
• Hospitalization for dental procedures is covered when the patient has another serious medical
condition that may complicate the dental procedure, such as serious blood disease, unstable
diabetes, or severe cardiovascular disease, or the patient is physically or developmentally disabled
with a dental condition that cannot be safely and effectively treated in a dental office. Coverage
requires preauthorization by PacificSource, and only charges for the facility, anesthesiologist, and
assistant physician are covered. Hospitalization because of the patient's apprehension or
convenience is not covered.
• This plan covers treatment for inborn errors of metabolism involving amino acid, carbohydrate,
and fat metabolism for which widely accepted standards of care exist for diagnosis, treatment, and
monitoring exist, including quantification of metabolites in blood, urine or spinal fluid or enzyme or.,
DNA confirmation in tissues. Coverage includes expenses for diagnosing, monitoring and
controlling the disorders by nutritional and medical assessment, including but not limited to clinical
visits, biochemical analysis and medical foods used in the treatment of such disorders. Nutritional
supplies are covered subject to the deductible, co-payment, and/or co-insurance stated in your
Medical Benefit Summary for durable medical equipment.
• Injectable drugs and biologicals administered by a physician are covered when medically
necessary for diagnosis or treatment of illness or injury. This benefit does not include
immunizations (see Preventive Care Services in this section) or drugs or biologicals that can be
self-administered or are dispensed to a patient.
SingleSource Self-Insured 44
Exhibit'&
• This plan covers maxillofacial prosthetic services when prescribed by a physician as necessary
to restore and manage head and facial structures. Coverage is provided only when head and facial
structures cannot be replaced with living tissue, and are defective because of disease, trauma, or
birth and developmental deformities. To be covered, treatment must be necessary to control or
eliminate pain or infection or to restore functions such as speech, swallowing, or chewing.
Coverage is limited to the least costly clinically appropriate treatment, as determined by the
physician. Cosmetic procedures and procedures to improve on the normal range of functions are
not covered. Dentures, prosthetic devices for treatment of TMJ conditions, and artificial larynx are
also not covered.
• Pediatric dental care is not covered.
• The routine costs of care associated with approved clinical trials are covered. Benefits are
only provided for routine costs of care associated with approved clinical trials. Expenses for
services or supplies that are not considered routine costs of care are not covered. For more
information, see 'routine costs of care' in the Definitions section of this Summary Plan Description.
A'qualifed individual' is someone who is eligible to participate in a qualifying clinical trial. If a
participating provider is participating in an approved clinical trial, the qualified individual may be
required to participate in the trial through that participating provider if the provider will accept the
individual as a participant in the trial.
• Sleep studies are covered when ordered by a pulmonologist, neurologist, otolaryngologist, or
certified sleep medicine specialist, and when performed at a certified sleep laboratory.
• This plan covers medically necessary therapy and services for the treatment of traumatic brain
injury.
• This plan covers tubal ligation and vasectomy procedures with no waiting period.
BENEFIT LIMITATIONS AND EXCLUSIONS
Least Costly Setting for Services
Covered services must be performed in the least costly setting where they can be provided safely. If a
procedure can be done safely in an outpatient setting but is performed in a hospital inpatient setting,
this plan will only pay what it would have paid for the procedure on an outpatient basis. If services are
performed in an inappropriate setting, your benefits can be reduced by up to 30 percent or $2,500,
whichever is less.
EXCLUDED SERVICES
A Note About Optional Benefits
If your Plan Sponsor provides coverage for optional benefits such as prescription drugs, vision services,
chiropractic care, or alternative care, you'll find those Member Benefit Summaries in this Summary Plan
Description. If your Plan Sponsor provides optional benefits for an exclusion listed below, then the
exclusion does not apply to the extent that coverage exists under the optional benefit. For example, if
your Plan Sponsor provides optional chiropractic coverage, then the exclusion for chiropractic care
listed below under 'Types of Treatment' does not apply to you.
Types of Treatment - This plan does not cover the following:
• Acupuncture
• Chelation therapy including associated infusions of vitamins and/or minerals, except as medically
necessary for the treatment of selected medical conditions and medically significant heavy metal
toxicities
• Day care or custodial care - Care and related services designed essentially to assist a person in
maintaining activities of daily living, e.g. services to assist with walking, getting inlout of bed,
bathing, dressing, feeding, preparation of meals, homemaker services, special diets, rest cures,
day care, and diapers. Custodial care is only covered in conjunction with respite care allowed under
this plan's hospice benefit. For related provisions, see 'Hospital and Skilled Nursing Facility
Services' and 'Home Health and Hospice Services' in the Covered Expenses section of this
Summary Plan Description.
SingleSource Self-Insured 45
Exhibit'B'
• Dental examinations and treatment, which means any services or supplies to prevent, diagnose, or
treat diseases of the teeth and supporting tissues or structures, except as specified in Covered
Expenses - Preventive Care Services except as specifically provided with a separate PacificSource
Dental Plan (See the Dental Benefit Plan section of this Summary Plan Description).
• Eye exercises, therapy, and procedures - Orthoptics, vision therapy, and procedures intended to
correct refractive errors
• Fitness or exercise programs and health or fitness club memberships
• Foot care (routine) - Services and supplies for corns and calluses of the feet, conditions of the
toenails other than infection, hypertrophy or hyperplasia of the skin of the feet, and other routine
foot care, except in the case of patients being treated for diabetes mellitus
• Genetic (DNA) testing, except for tests identified as medically necessary for the diagnosis and
standard treatment of specific diseases
• Homeopathic treatment
• Infertility - Services and supplies, surgery, treatment, or prescriptions to prevent, or cure infertility
or to induce fertility (including Gamete and/or Zygote Interfallopian Transfer; i.e. GIFT or ZIFT),
except for medically necessary medication to preserve fertility during treatment with cytotoxic
chemotherapy. For related provisions, see the exclusion for 'family planning' in this section. For
purposes of this plan, infertility is defined as:
o Male: Low sperm counts or the inability to fertilize an egg
o Female: The inability to conceive or carry a pregnancy to 12 weeks
• Instructional or educational programs, except diabetes self-management programs
• Jaw - Services or supplies for developmental or degenerative abnormalities of the jaw,
malocclusion, dental implants, or improving placement of dentures.
• Massage, massage therapy, or neuromuscular re-education, even as part of a physical therapy
program
• Motion analysis, including videotaping and 3-D kinematics, dynamic surface and fine wire
electromyography, and physician review
• Myeloablative high dose chemotherapy, except when the related transplant is specifically covered
under the transplantation provisions of this plan. For related provisions, see 'Transplant Services' in
the Covered Expenses section of this Summary Plan Description.
• Naturopathic treatment
• Obesity or weight control - Surgery or other related services or supplies provided for weight control
or obesity (including all categories of obesity) except as listed under 'Preventive Care Services',
whether or not there are other medical conditions related to or caused by obesity. This also
includes services or supplies used for weight loss, such as food supplementation programs and
behavior modification programs, regardless of the medical conditions that may be caused or
exacerbated by excess weight, and self-help or training programs for weight control. Obesity
screening and counseling are covered for children and adults; see the 'dietary or nutritional
counseling' section under'Other Covered Services'.
• Oral/facial motor therapy for strengthening and coordination of speech-producing musculature and
structures
• Osteopathic manipulation, except for treatment of disorders of the musculoskeletal system
• Physical or eye examinations required for administrative purposes such as participation in athletics,
admission to school, or by a Plan Sponsor
• Private nursing service
• Programs that teach a person to use medical equipment, care for family members, or self
administer drugs or nutrition (except for diabetic education benefit)
• Rehabilitation - Functional capacity evaluations, work hardening programs, vocational
rehabilitation, community reintegration services, and driving evaluations and training programs
• Routine services and supplies - Services, supplies, and equipment not involved in diagnosis or
treatment but provided primarily for the comfort, convenience, cosmetic purpose, environmental
SingleSource Self-Insured 46
Exhibit'B'
control, or education of a patient or for the processing of records or claims. These include but are
not limited to:
o Missed appointments, completion of claim forms, or reports requested by PacificSource in
order to process claims
o Appliances, such as air conditioners, humidifiers, air filters, whirlpools, hot tubs, heat
lamps, or tanning lights
o Private nursing services or personal items such as telephones, televisions, and guest
meals in a hospital or skilled nursing facility
o Maintenance supplies and equipment not unique to medical care
• Screening tests - Services and supplies, including imaging and screening exams performed for the
sole purpose of screening and not associated with specific diagnoses and/or signs and symptoms
of disease or of abnormalities on prior testing (including but not limited to total body CT imaging, CT
colonography and bone density testing).This does not include preventive care screenings listed
under 'Preventive Care Services' in the Covered Expenses section of this Summary Plan
Description.
• Self-help or training programs
• Sexual disorders - Services or supplies for the treatment of sexual dysfunction or inadequacy
unless medically necessary to treat a mental health issue and diagnosis. For related provisions,
see the exclusions for'family planning', 'infertility', and 'mental illness' in this section.
• Snoring - Services or supplies for the diagnosis or treatment of snoring or upper airway resistance
disorders, including somnoplasty
• Speech therapy - Oral/facial motor therapy for strengthening and coordination of speech-producing
muscles and structures, except as medically necessary in the restoration or improvement of speech
following a traumatic brain injury or for a child 17 years of age or younger diagnosed with a
pervasive developmental disorder.
• Temporomandibular joint (TMJ)-related services, or treatment for associated myofascial pain,
including physical or oromyofacial therapy
Surgeries and Procedures - This plan does not cover the following:
• Abdominoplasty for any indication
• Artificial insemination, in vitro fertilization, or GIFT procedures
• Cosmetic/reconstructive services and supplies - Except as specified in the Covered Expenses -
Other Covered Services, Supplies, and Treatments section of this Summary Plan Description,
services and supplies, including drugs, rendered primarily for cosmetic/reconstructive purposes and
any complications as a result of non-covered cosmetic/reconstructive surgery.
Cosmetic/reconstructive services and supplies are those performed primarily to improve the body's
appearance and not primarily to restore impaired function of the body, regardless of whether the
area to be treated is normal or abnormal.
• Electronic Beam Tomography (EBT)
• Eye refraction procedures, orthoptics, vision therapy, or other services to correct refractive error
except as indicated in the Covered Services section of this Summary Plan Description
• Jaw surgery - Treatment for abnormalities of the jaw, malocclusion, or improving the placement of
dentures and dental implants
• Orthognathic surgery - Services and supplies to augment or reduce the upper or lower jaw, except
as specified under 'Professional Services' in the Covered Expenses section of this Summary Plan
Description.
• Panniculectomy for any indication
• Sex reassignment - Procedures, services or supplies related to a sex reassignment unless
medically necessary. For related provisions, see exclusions for'mental illness' in this section.
o Excluded procedures include, but are not limited to: staged gender reassignment surgery,
including breast augmentation; penile implantation; liposuction, thyroid chondroplasty,
SingleSource Self-Insured 47
Exhibit B'
laryngoplasty, or shortening of the vocal cords, and/or hair removal specifically to assist the
appearance of other characteristics of gender reassignment.
• Surgery to reverse voluntary sterilization
• Transplants -Any services, treatments, or supplies for the transplantation of bone marrow or
peripheral blood stem cells or any human body organ or tissue, except as expressly provided under
the provisions of this plan for covered transplantation expenses. For related provisions see
'Transplant Services' in the Covered Expenses section of this Summary Plan Description.
Mental Health Services - This plan does not cover the following services, whether provided by a
mental health or chemical dependency specialist or by any other provider:
Treatment for the following diagnosis:
• Diagnostic codes V 15.81 through V71.09 (DSM-IV-TR, Forth Edition) except V61.20, V61.21, and
V62.82 when used with children five years of age or younger
• Food dependencies
• Gender Identity Disorders in Adults (GID)
• Learning disorders
• Mental illness does not include - Treatment of intellectual disabilities, learning disorders;
paraphilias; and relationship problems (e.g. parent-child, partner, sibling, or other relationship
issues), except the treatment of children five years of age or younger for parent-child relational
problems, physical abuse of a child, sexual abuse of a child, neglect of a child, or bereavement.
This plan does not cover educational or correctional services or sheltered living provided by a
school or halfway house, except outpatient services received while temporarily living in a shelter;
psychoanalysis or psychotherapy received as part of an educational or training program, regardless
of diagnosis or symptoms that may be present; a court-ordered sex offender treatment program; a
court-ordered screening interview or drug or alcohol treatment program; or nicotine related
disorders.
The following treatment types are also excluded, regardless of diagnosis: marital/partner
counseling; support groups; sensory integration training; biofeedback except to treat migraine
headaches or urinary incontinence; hypnotherapy; academic skills training; narcosynthesis;
aversion therapy; and social skill training. Recreation therapy is only covered as part of an inpatient
or residential admission.
The following are also excluded: court-mandated diversion and/or chemical dependency education
classes; court-mandated psychological evaluations for child custody determinations; voluntary
mutual support groups such as Alcoholics Anonymous; adolescent wilderness treatment programs;
mental examinations for the purpose of adjudication of legal rights; psychological testing and
evaluations not provided as an adjunct to treatment or diagnosis of a stress management,
parenting skills, or family education; assertiveness training, image therapy; sensory movement
group therapy; marathon group therapy; sensitivity training; and psychological evaluation for sexual
dysfunction or inadequacy.
• Mental retardation for individuals 18 years of age or older
• Nicotine related disorders
• Paraphilias
Treatment programs, training, or therapy as follows:
• Academic skills training
• Aversion therapy T
• Biofeedback (other than as specifically noted under the Covered Expenses - Other covered
Services, Supplies, and Treatment section)
• Court-ordered sex offender treatment programs
• Court-ordered screening interviews or drug or alcohol treatment programs
• Educational or correctional services or sheltered living provided by a school or halfway house
• Equine/animal therapy
SingleSource Self-Insured 48
Exhibit 'B'
• Hypnotherapy
• Narcosynthesis
• Psychoanalysis or psychotherapy received as part of an educational or training program,
regardless of diagnosis or symptoms that may be present
• Marital/partner counseling
• Recreation therapy outside a inpatient or residential treatment setting
• Sensory integration training
• Social skill training
• Support groups
Drugs and Medications - This plan does not cover the following:
• Drugs and biologicals that can be self administered (including injectibles), other than those
provided in a hospital emergency room, or other institutional setting, or as outpatient chemotherapy
and dialysis, which are covered
• Drugs or medications not prescribed for inborn errors of metabolism, diabetic insulin, or autism
spectrum disorder that can be self-administered (including prescription drugs, injectable drugs, and
biologicals), unless given during a visit for outpatient chemotherapy or dialysis or during a medically
necessary hospital, emergency room or other institutional stay.
• Growth hormone injections or treatments, except to treat documented growth hormone deficiencies
• Immunizations when recommended for or in anticipation of exposure through travel or work
• Over-the-counter medications or non-prescription drugs
Equipment and Devices - This plan does not cover the following:
• Computer or electronic equipment for monitoring asthmatic, diabetic, or similar medical conditions
or related data
• Equipment commonly used for nonmedical purposes - This plan does not cover the following:
o Equipment commonly used for nonmedical purposes, or marketed to the general public, or
intended to alter the physical environment. This includes appliances like adjustable power
beds sold as furniture, air conditioners, air purifiers, room humidifiers, heating and cooling
pads, home blood pressure monitoring equipment, light boxes, conveyances other than
conventional wheelchairs, whirlpool baths, spas, saunas, heat lamps, tanning lights, and
pillows. It also includes orthopedic shoes and shoe modifications. Mattresses and mattress
pads are only covered when medically necessary to heal pressure sores.
o Modifications to vehicles or structures to prevent, treat, or accommodate a medical
condition
o Replacement costs for worn or damaged durable medical equipment that would otherwise
be replaceable without charge under warranty or other agreement
o Personal items such as telephones, televisions, and guest meals during a stay at a hospital
or other inpatient facility
• Equipment used primarily in athletic or recreational activities. This includes exercise equipment for
stretching, conditioning, strengthening, or relief of musculoskeletal problems
• Modifications to vehicles or structures to prevent, treat, or accommodate a medical condition
• Personal items such as telephones, televisions, and guest meals during a stay at a hospital or other
inpatient facility
• Replacement costs for worn or damaged durable medical equipment that would otherwise be
replaceable without charges under warranty or other agreement
Experimental or Investigational Treatment
Your Plan Sponsors plan does not cover experimental or investigational treatment. By that,
PacificSource means services, supplies, protocols, procedures, devices, chemotherapy, drugs or
SingleSource Self-Insured 49
Exhibit'B'
medicines or the use thereof that are experimental or investigational for the diagnosis and treatment of
the patient. It includes treatment that, when and for the purpose rendered:
• Has not yet received full U.S. government agency approval (e.g. FDA) for other than experimental,
investigational, or clinical testing;
• Is not of generally accepted medical practice in Oregon or as determined by PacificSource in
consultation with medical advisors, medical associations, and/or technology resources;
• Is not approved for reimbursement by the Centers for Medicare and Medicaid Services;
• Is furnished in connection with medical or other research; or
• Is considered by any governmental agency or subdivision to be experimental or investigational, not
reasonable and necessary, or any similar finding.
An experimental or investigational service is not made eligible for benefits by the fact that other
treatment is considered by your healthcare provider to be ineffective or not as effective as the service or
that the service is prescribed as the most likely to prolong life.
When making benefit determinations about whether treatments are investigational or experimental,
PacificSource relies on the above resources as well as:
• Expert opinions of specialists and other medical authorities;
• Published articles in peer-reviewed medical literature;
• External agencies whose role is the evaluation of new technologies and drugs; and
• External review by an independent review organization.
The following will be considered in making the determination whether the service is in an experimental
and/or investigational status:
• Whether there is sufficient evidence to permit conclusions concerning the effect of the services on
health outcomes;
• Whether the scientific evidence demonstrates that the services improve health outcomes as much
or more than established alternatives;
• Whether the scientific evidence demonstrates that the services' beneficial effects outweigh any
harmful effects; and
• Whether any improved health outcomes from the services are attainable outside an investigational
setting.
If you or your provider have any concerns about whether a course of treatment will be covered,
PacificSource encourages you to contact PacificSource's Customer Service Department. PacificSource
will arrange for medical review of your case against PacificSource's criteria, and notify you of whether
the proposed treatment will be covered.
Other Items - This plan does not cover the following:
• Treatment not medically necessary - Services or supplies that are not medically necessary for the
diagnosis or treatment of an illness, injury, or disease. For related provisions, see 'medically
necessary' in the Definitions section and 'Understanding Medical Necessity' in the Covered
Expenses section of this Summary Plan Description.
• Treatment prior to enrollment - Services or supplies a member received prior to enrolling in
coverage provided by this plan; charges for inpatient stays that begin before you were covered by
this plan; services or supplies received before this plan's coverage began; admission prior to "
coverage; services and supplies for an admission to a hospital, skilled nursing facility or specialized
facility that began before the patient's coverage under this plan
• Treatment after insurance ends - Services or supplies received after enrollment in this policy ends.
(The only exception is if this policy is replaced by another group health policy while you are
hospitalized. The plan will continue paying covered hospital expenses until you are released or your
benefits are exhausted, whichever occurs first.)
• Care and related services designed essentially to assist a person in maintaining activities of daily
living, e.g. services to assist with walking, getting in/out of bed, bathing, dressing, feeding, and
SingleSource Self-Insured 50
Exhibit'B'
preparation of meals, homemaker services, special diets, rest crew, day care, and diapers.
Custodial care is only covered in conjunction with respite care allowed under this policy's hospice
benefit (see Covered Expenses - Hospital, Skilled Nursing Facility, Home Health, and Hospice
Services).
• Services or supplies available to you from another source, including those available through a
government agency
• Services or supplies for which no charge is made, for which the member is not legally required to
pay, or for which a provider or facility is not licensed to provide even though the service or supply
may otherwise be eligible. This exclusion includes services provided by the member, or by an
immediate family member.
• Services or supplies for which you are not willing to release the medical or eligibility information
PacificSource needs to determine the benefits paid under this plan
• Charges that are the responsibility of a third party who may have caused the illness, injury, or
disease or other insurers covering the incident (such as workers' compensation insurers,
automobile insurers, and general liability insurers)
• Charges over the usual, customary, and reasonable fee (UCR) - Any amount in excess of the UCR
for a given service or supply, except alternative care.
• Treatment of any illness, injury, or disease resulting from an illegal occupation or attempted felony,
or treatment received while in the custody of any law enforcement authority
• Treatment of any condition caused by a war, armed invasion, or act of aggression, or while serving
in the armed forces
• Treatment of any work-related illness or injury, unless you are the owner, partner, or principal of the
Plan Sponsor, injured in the course of employment of the Plan Sponsor, and are otherwise exempt
from, and not covered by, state or federal workers' compensation insurance. This includes illness or
injury caused by any for-profit activity, whether through employment or self-employment.
• Treatment while incarcerated - Services or supplies a member receives while in the custody of any
state or federal law enforcement authorities or while in jail or prison
• Charges for phone consultations, missed appointments, get acquainted visits, completion of claim
forms, or reports PacificSource needs to process claims
• Any amounts in excess of the allowable fee for a given service or supply Training or self-help
programs - General fitness exercise programs, and programs that teach a person how to use
durable medical equipment or care for a family member. Also excluded are health or fitness club
services or memberships and instruction programs, including but not limited to those to learn to
self-administer drugs or nutrition, except as specifically provided for in this plan.
• Services of providers who are not eligible for reimbursement under this plan. An individual
organization, facility, or program is not eligible for reimbursement for services or supplies,
regardless of whether this plan includes benefits for such services or supplies, unless the
individual, organization, facility, or program is licensed by the state in which services are provided
as an independent practitioner, hospital, ambulatory surgical center, skilled nursing facility, durable
medical equipment supplier, or mental and/or chemical healthcare facility. And to the extent
PacificSource maintains credentialing requirements the practitioner or facility must satisfy those
requirements in order to be considered an eligible provider.
• Scheduled and/or non-emergent medical care outside of the United States.
• Services otherwise available - These include but are not limited to:
o Services or supplies for which payment could be obtained in whole or in part if the member
applied for payment under any city, county, state (except Medicaid), or federal law; and
o Services or supplies the member could have received in a hospital or program operated by
a federal government agency or authority, except otherwise covered expenses for services
or supplies furnished to a member by the Veterans' Administration of the United States that
are not military service-related.
This exclusion does not apply to covered services provided through Medicaid or by any hospital
owned or operated by the State of Oregon or any state-approved community mental health and
developmental disability program.
SingleSource Self-Insured 51
Exhibit'B'
• Benefits not stated - Services and supplies not specifically described as benefits under the group
health policy and/or any endorsement attached hereto
EXCLUSION PERIODS
Exclusion Period for Transplant Benerts
Except for corneal transplants, organ and tissue transplants are not covered until you have been
enrolled in this plan for 24 months or since birth. If you were covered under another health insurance
plan before enrolling in this plan, you can receive credit for your prior coverage. See the Credit for Prior
Coverage section, below.
CREDIT FOR PRIOR COVERAGE
You can receive credit toward this plan's exclusion periods if you had qualifying healthcare coverage
before enrolling in this plan. To qualify for this credit, there may not have been more than a 63-day
gap between your last day of coverage under the previous health plan and your first day of coverage
(or the first day of your Plan Sponsor's probationary waiting period) under this plan.
Your prior coverage must have been a group health plan, COBRA or state continuation coverage,
individual health policy (including student plans), Medicare, Medicaid, TRICARE, State Children's
Health Insurance Program, and coverage through high risk pools and the Peace Corps. If you were
covered as a dependent under a plan that meets these qualifications, you will qualify for credit. Many
people elect the COBRA or state continuation coverage available under a prior plan to make sure they
won't have more than a 63-day gap in coverage.
It is your responsibility to show you had creditable coverage. If you qualify for credit, PacificSource
will count every day of coverage under your prior plan toward this plan's exclusion periods for pre-
existing conditions, other specified conditions, and transplants (explained above).
Evidence of Prior Creditable Coverage
You can show evidence of creditable coverage by sending PacificSource a Certificate of Creditable
Coverage from your previous health plan. All health plans, insurance companies, and HMOs are
required by law to provide these certificates on request. Most insurers issue these certificates
automatically whenever someone's coverage ends. The certificate shows how long you were covered
under your previous plan and when your coverage ended.
If you do not have a certificate of prior coverage, contact your previous insurance company or Plan
Sponsor (such as your former employer, if you had a group health plan). You have the right to request a
certificate from any prior plan, insurer, HMO, or other entity through which you had creditable coverage.
If you are unable to obtain a certificate, contact PacificSource's Membership Services Department for
assistance.
HEALTH CARE MANAGEMENT AND PREAUTHORIZATION
What is Health Care Management
Your Plan Sponsor desires to provide you and your family with a heath care benefit plan that financially
protects you from significant health care expenses and assures you quality care. While part of
increasing health care costs results from new technology and important medical advances, another
significant cause is the way health care services are used.
lP.
Some studies indicate that a high percentage of the cost for health care services may be unnecessary.
For example, hospital stays may be longer than necessary. Some hospitalizations may be entirely
avoidable, such as when surgery could be performed at an outpatient facility with equal quality and
safety. Also, surgery is sometimes performed when other treatment could be more effective. All of these
instances increase costs for you and the plan.
Your Plan Sponsor has contracted with PacificSource to assist you in determining whether or not
proposed services are appropriate for reimbursement under this plan. The program is not intended to
diagnose or treat medical conditions, dictate a treatment plan, guarantee benefits, or validate eligibility.
SingleSource Self-Insured 52
Exhibit V
The medical professionals who conduct the program focus their review on the appropriateness for
reimbursement of hospital stays and proposed surgical procedures.
Required Admission Review - You are required to call PacificSource's toll-free number, (888) 977-
9299, prior to any elective inpatient stay or any scheduled surgical procedure. In most cases, your
medical provider will make the call for you. You must also call within 48 hours of any emergency
admission. When you or your provider call, it will be necessary to provide the program with your name,
the patient's name, the name of the physician or practitionerand hospital, the reason for the
hospitalization and any other information needed to complete the review. In some cases, you may be
asked for more information or a second opinion may be required to complete the review.
Preauthorization - Preauthorization is necessary to determine if certain services and supplies are
covered under this plan and if you meet the plan's eligibility requirements. PacificSource reviews new
technologies and standards of medical practice on an ongoing basis and therefore the list of
preauthorization requirements is subject to changes and updates. The current list of procedures and
services that require preauthorization under the plan can be found the PacificSource' website:
PacificSource.com.
The list of services that require preauthorization is not intended to suggest that all the items
included are necessarily covered by the benefits of this plan.
A request for preauthorization must be made to PacificSource as soon as the patient knows that he or
she will be receiving services for which preauthorization is required. Your medical provider can request
preauthorization from PacificSource by phone - (888) 977-9299, fax - (541) 684-5264, or mail:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extension 1009
cs@pacificsou rce. com
If your provider will not request preauthorization for you, you may contact PacificSource yourself. In
some cases, you may be asked for more information or be required to obtain a second opinion before a
benefit determination can be made.
If you are preauthorized for one facility, but are then transferred to another facility you will need to
obtain preauthorization for the new facility before transferring, except in the case of emergencies in
which case notification must be made as soon as possible after transferring facilities.
If your provider's preauthorization request is denied as not medically necessary or as experimental,
your provider may appeal the adverse benefit determination. You retain the right to appeal the adverse
benefit determination independent from your provider.
Note: A preauthorization determination is valid for 90 days. However, if your coverage under the plan
ends before the services are rendered or supplies received, the preauthorization determination will
become invalid.
Case Management
The primary objective of large case management is to identify and coordinate cost-effective medical
care alternatives and to help manage the care of patients who have special or extended care illnesses
or injuries. Large case management also monitors the care of the patient, offers emotional support to
the family, and coordinates communications among health care providers, patients and others.
Benefits may be modified by the Plan Sponsor to permit a method of treatment not expressly provided
for, but not prohibited by law, rules or public policy, if the Plan Sponsor determines that such
modification is medically necessary and is more cost-effective than continuing a benefit to which you or
your eligible dependents may otherwise be entitled. The Plan Sponsor also reserves the right to limit
payment for services to those amounts which would have been charged had the service been provided
in the most cost-effective setting in which the service could safely have been provided.
Examples of illnesses or injuries that may be appropriate for large case management include, but are not
limited to:
SingleSource Self-Insured 53
Exhibit'B'
• Terminal illnesses (Cancer, AIDS, Multiple Sclerosis, Renal Failure, Obstructive Pulmonary
Disease, Cardiac conditions, etc.)
• Accident victims requiring long-term rehabilitative care
• Newborns with high-risk complications or multiple birth defects
• Diagnoses involving long-term IV therapy
• Illnesses not responding to medical care
• Child and adolescent mental/nervous disorders
• Organ transplants
individual Benefits Management
Individual benefits management addresses, as an alternative to providing covered services,
PacificSource's consideration of economically justified alternative benefits. The decision to allow
alternative benefits will be made by on a case-by-case basis. The determination to cover and pay for
alternative benefits for an individual shall not be deemed to waive, alter or affect the Plan Sponsor's or
PacificSource's right to reject any other or subsequent request or recommendation. The Plan Sponsor
may provide alternative benefits if PacificSource and the individual's attending provider concur in the
request for and in the advisability of alternative benefits in lieu of specified covered services, and, in
addition, PacificSource concludes that substantial future expenditures for covered services for the
individual could be significantly diminished by providing such alternative benefits under the individual
benefit management program (See Case Management above).
HOW TO USE YOUR DENTAL PLAN
When you need dental care, you may visit any dentist. Most dental offices will bill PacificSource directly.
If your dentist has any questions regarding billing procedures, he or she can call PacificSource at (541)
225-1981, or (866) 373-7053 from outside the Eugene-Springfield area.
When you first visit your dentist after becoming covered under this plan, let the office staff know you
have dental benefits through PacificSource. You will need to show your PacificSource ID card, which
contains your group number and benefit information. Your dentist may submit claims and treatment
programs on a standard American Dental Association form.
For extensive dental work, PacificSource recommends that your dentist submit a pre-treatment
estimate to PacificSource. PacificSource then determines how much your plan will pay toward the
proposed treatment and review the estimate with your dentist prior to treatment. If your covered family
members require extensive dental work, be sure your member ID number and group number are
included on their pre-treatment form for identification purposes.
DENTAL PLAN BENEFITS
When this plan pays for dental services, it actually pays the stated percentage of charges based on
reasonable and customary charges. A charge is reasonable and customary when it falls within a
general range of charges being made by most dental providers in your service area for similar
treatment of similar dental conditions. If the charge for a treatment or service is more than the
reasonable and customary charge in your service area, you may be required to pay the difference. The
reasonable and customary charge for dental expense is the 'covered charge' referred to in this booklet.
If you or your covered family member selects a more expensive treatment than is customarily provided,
this plan will pay the applicable percentage of the lesser fee. You will be responsible for the balance of
the provider's charges.
With the Advantage Network, participating dentists agree to write off any charges over and above the
negotiated, contracted fees for most services. When you use a participating dentist in the Advantage
Network, you will not be responsible for any excess charges and will pay only your plan's deductible
and/or co-insurance amount. If you choose not to use a participating Advantage Network dentist, or
don't have access to them, reimbursement will continue to be based on usual, customary, and
reasonable (UCR) charges. If that non-participating dentist's fees exceed the UCR charges, the excess
charges are also your responsibility
SingleSource Self-Insured 54
Exhibit'B'
COVERED DENTAL SERVICES
This dental plan covers the following services when performed by an eligible provider and when
determined to be necessary by the standards of generally accepted dental practice for the prevention or
treatment of oral disease or for accidental injury, including masticatory function. Covered services may
also be provided by a dental hygienist or denturist to the extent that he or she is operating within the
scope of his or her license as required under law in the State of Oregon.
Covered dental services are organized into three classes, starting with preventive care and advancing
into specialized dental procedures.
Class / Services - Diagnostic and Preventive Treatment
• Examinations (routine or other diagnostic exams) are covered. Separate charges for review of a
proposed treatment plan or for diagnostic aids such as study models and certain lab tests are not
covered.
• Full mouth x-rays and/or panorex are covered up to one complete mouth series and/or panorex
in any three-year period and limited to four bite-wing films in a six-month period. When an
accumulative charge for additional periapical x-rays in a one-year period matches that of a
complete mouth series, no further benefits for periapical x-rays or panorex are available for the
remainder of the year.
• Dental cleanings (prophylaxis and periodontal maintenance) are covered to a combined total
of three procedures per person per benefit year. The limitation for dental cleaning applies to any
combination of prophylaxis and/or periodontal maintenance in the benefit year. A separate charge
for periodontal charting is not a covered benefit. Periodontal maintenance is not covered when
performed within three months of periodontal scaling and root planing and/or curettage.
• Topical applications of fluoride are covered to two applications per benefit year through age 22.
• Fluoride varnish applications are covered to 12 applications per benefit year for children age 12
and under if the child is deemed at risk for dental infection.
• The application of sealants is covered to one application in a five-year period to permanent
molars and bicuspids and only for individuals through age 17.
• Vizilite is a covered up to two screenings per benefit year.
• Benefits for athletic mouth guards are limited to one per lifetime through age 17 if the member is
still in secondary school.
• Benefits for brush biopsies used to aid in the diagnosis of oral cancer are covered.
Class Restorative Services - Basic and Restorative Treatment
• Composite, resin, or similar restoration in a posterior (back) tooth is covered to the amount that
would be paid for a corresponding amalgam restoration. A separate charge for anesthesia when
used during restorative procedures is not a covered benefit. Only one filling is allowed per tooth
surface. The Plan Sponsorwill pay for a filling on a tooth surface only once per benefit year. Three
or more surface fillings are limited to one per surface per benefit year.
• Simple and surgical extractions of teeth and other minor oral surgery procedures are covered.
General anesthesia used in conjunction with these extractions administered by a dentist in a dental
office is also covered. A separate charge for alveolectomy performed in conjunction with removal of
teeth is not a covered benefit.
• Periodontal scaling and root planing and/or curettage is covered but limited to only one
procedure per quadrant in any 24-month period. For the purpose of this limitation, eight or fewer
teeth existing in one arch will be considered one quadrant.
• Benefits for full mouth debridement are limited to once every 24 months. This procedure is only
covered if the teeth have not received a prophylaxis in the prior 24 months and if an evaluation
cannot be performed due to the obstruction by plaque and calculus on the teeth. This procedure is
not covered if performed on the same date as the prophylaxis.
Class Complicated Services - Complicated Treatment
• Complicated oral surgical procedures such as removal of impacted teeth are covered when
SingleSource Self-Insured 55
Exhibit V
preauthorized by PacificSource. Benefits for complicated oral surgical procedures include general
anesthesia administered by a dentist in a dental office. A separate charge for alveolectomy
performed in conjunction with removal of teeth is not a covered benefit.
• Pulp capping is covered only when there is an exposure to the pulp. These are direct pulp caps.
Indirect pulp caps are not covered.
• Pulpotomy is covered only for deciduous teeth.
• Root canal therapy is covered on the same tooth only for one charge in a three-year period.
• Periodontal surgery is covered when the procedure is preauthorized by PacificSource and
accompanied by a periodontal diagnosis and history of conservative (non-surgical) periodontal
treatment.
• Tooth desensitization is covered as a separate procedure from other dental treatment.
• Space maintainers are a covered benefit for individuals through the age of 13.
Class IM Services - Majai Tieatmefft
• Crowns and other cast or laboratory-processed restorations are covered but limited to the
restoration of any one tooth in a five-year period. If a tooth can be restored with a material such as
amalgam o, r composite resin, covered charges are limited to the cost of amalgam or non-laboratory
composite resin restoration even if another type of restoration is selected by the patient and/or
dentist.
• Replacement of an existing prosthetic device is covered only when the device being replaced is
unserviceable, cannot be made serviceable, and has been in place for at least five years.
• Cast partial denture, full, immediate, or overdenture are covered only to the cost of a standard
full or cast partial denture. A separate charge for denture adjustments and relines performed within
six months of the initial placement is not a covered benefit. Benefits for subsequent relines are
provided only once in a 12-month period. Cast restorations for partial denture abutment teeth or for
splinting purposes are not covered unless the tooth in and of itself requires a cast restoration.
• Fixed bridges or removable cast partials are covered. Benefits for temporary full or partial
dentures must be preauthorized. Benefits for the initial placement of full or partial dentures or fixed
bridges (including acid-etch metal bridges) are provided only if the denture or bridgework includes
replacement of a natural tooth which is extracted or lost while the member's coverage is in effect.
However, this limitation does not apply after the member has been covered under the policyholder's
group dental plan for a period of at least 36 consecutive months.
• Benefits for the surgical placement and removal of implants are limited to once per lifetime per
tooth space for each service. Services must be preauthorized by PacificSource to be covered.
Benefits include final crown and implant abutment over a single implant and final implant-supported
bridge abutment and implant abutment or pontic. An alternative benefit per arch of a conventional
full or partial denture for the final implant-supported full or partial denture prosthetic device is
available.
• Bruxism splint and nightguard (appliances to reduce or prevent pain or damage from grinding of
teeth) are covered.
ORTHODONTIA BENEFITS
This plan pays 50% of the usual, customary, and reasonable for orthodontics for all covered individuals.
The lifetime maximum amount payable for orthodontic benefits is $1,000 per person.
EXCLUDED DENTAL SERVICES
This plan does not provide benefits in any of the following circumstances or for any of the following
conditions:
• Aesthetic dental procedures - Services and supplies provided in connection with dental
procedures that are primarily aesthetic, including bleaching of teeth and labial veneers.
• Antimicrobial agents - Localized delivery of antimicrobial agents into diseased crevicular tissue
via a controlled release vehicle.
SingleSource Self-Insured 56
Exhibit'B'
• Benefits not stated - Any services and supplies not specifically described as covered benefits
under this plan
• Biopsies or histopathologic exams - A separate charge for a biopsy of oral tissue or
histopathologic exam.
• Bone replacement grafts to prepare sockets for implants after tooth extraction.
• Charges for broken appointments
• Collection of cultures and specimens.
• Connector bar or stress breaker.
• Core build-ups are not covered unless used to restore a tooth that has been treated
endodontically (root canal).
• Cosmetic/reconstructive services and supplies - Procedures, appliances, restorations, or other
services that are primarily for cosmetic purposes. This includes services or supplies rendered
primarily to correct congenital or developmental malformations, including but not limited to, peg
laterals, cleft palate, maxillary and mandibular (upper and lower jaw) malformation, enamel
hypoplasia, and fluorosis (discoloration of teeth). However, the replacement of congenitally missing
teeth is covered.
• Denture replacement made by necessary by loss, theft, or breakage.
• Diagnostic casts - Diagnostic casts (study models), gnathological recordings, occlusal
appliances, occlusal equilibration procedures, or similar procedures.
• Drugs and medications that are prescribed drugs, premedication drugs, analgesics (e.g., nitrous
oxide or non-intravenous sedation), any other euphoric drugs, or any take-home medicine or
supplies distributed by a provider.
• Educational programs - Instructions and/or training in plaque control and oral hygiene.
• Experimental or investigational procedures - Services, supplies, protocols, procedures,
devices, drugs or medicines, or the use thereof that are experimental or investigational for the
diagnosis and treatment of the patient. An experimental or investigational service is not made
eligible for benefits by the fact that other treatment is considered by the member's dental care
provider to be ineffective or not as effective as the service or that the service is prescribed as the
most likely to prolong life.
• Fractures of the mandible - Services and supplies provided in connection with the treatment of
simple or compound fractures of the mandible.
• General anesthesia except when administered by a dentist in connection with oral surgery in
his/her office
• Gingivetomcy, gingivoplasty or crown lengthening in conjunction with crown preparation or
fixed bridge services done on the same date of service.
• Hospital charges or additional fees charged by the dentist for hospital treatment
• Hypnosis
• Infection control - A separate charge for infection control or sterilization
• Intra and extra coronal splinting - Devices and procedures for intra and extra coronal splinting to
stabilize mobile teeth.
• Oral Surgery treating any fractured jaw
• Orthodontic services - Treatment of malalignment of teeth and/or jaws, or any ancillary services
expressly performed because of orthodontic treatment, unless your Dental Benefit Summary shows
orthodontic services as a covered benefit.
• Orthognathic surgery - Surgery to manipulate facial bones, including the jaw, in patients with
facial bone abnormalities performed to restore the proper anatomic and functional relationship to
the facial bones
• Periodontal probing, charting, and re-evaluations
• Photographic images.
SingleSource Self-Insured 57
Exhibit B'
• Pin retention in addition to restoration.
• Precision attachments
• Pulpotomies on permanent teeth
• Removal of clinically serviceable amalgam restorations to be replaced by other materials free
of mercury, except with proof of allergy to mercury.
• Services covered by the member's medical plan.
• Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or
occlusion, or for stabilizing the teeth.
• Services otherwise available - These include but are not limited to:
- Services or supplies for which payment could be obtained in whole or in part if the member
applied for payment under any city, county, state, or federal law (except Medicaid); and
- Services or supplies the member could have received in a hospital or program operated by a
federal government agency or authority. Covered expenses for services or supplies furnished
to a member by the Veterans' Administration of the United States that are not service-related
are eligible for payment according to the terms of this policy.
- Services or supplies for which payment would be made by Medicare.
• Services or supplies for which no charge is made which you are not legally required to pay or
which a provider or facility is not licensed to provide even though the service or supply may
otherwise be eligible. This includes services provided by you or an immediate family member.
• Sinus lift grafts to prepare sinus site for implants.
• Temporomandibular joint (TMJ) -Any services or supplies for treatment of any disturbance of
the Temporomandibular joint.
• Third party liability, motor vehicle liability, motor vehicle insurance coverage, workers'
compensation - Any services or supplies for illness or injury for which a third party is responsible
or which are payable by such third party or which are payable pursuant to applicable workers'
compensation laws, motor vehicle liability, uninsured motorist, underinsured motorist, and personal
injury protection insurance and any other liability and voluntary medical or dental payment
insurance to the extent of any recovery received from or on behalf of such sources.
• Tooth transplantation - Services and supplies provided in connection with tooth transplantation,
including re-implantation from one site to another and splinting and/or stabilization. This exclusion
does not relate to the re-implantation of a tooth into its original socket after it has been avulsed.
• Treatment after insurance ends - Services or supplies provided after enrollment in this plan
ends. The only exception is for Class III Services ordered and fitted before enrollment ends and
placed within 31 days after enrollment ends.
• Treatment not dentally necessary according to acceptable dental practice or treatment not likely
to have a reasonably favorable prognosis.
• Treatment prior to enrollment - Dental services begun before you or your family member
became eligible for those services under this plan.
• Treatment while incarcerated - Services or supplies received while in the custody of any state or
federal law enforcement authorities or while in jail or prison.
• Unwilling to release information - Charges for services or supplies for which you are unwilling to
release medical or dental information necessary to determine eligibility for payment under this
policy
• War-related conditions - The treatment of any condition caused by or arising out of an act of war,
armed invasion, or aggression, or while in the service of the armed forces.
• Work-related conditions - Services or supplies for treatment of illness or injury arising out of or in
the course of employment or self-employment for wages or profit, whether or not the expense for
the service or supply is paid under workers' compensation.
SingleSource Self-Insured 58
Exhibit'B'
CLAIMS PROCEDURES
How to File/How to Appeal a Claim
These claim procedures describe how benefit claims and appeals are made and decided under this
plan.
Only members or a designated authorized representative may submit claims for benefits (for
themselves and on behalf of their covered dependents), and benefits will only be paid to the member or
the actual provider of services. Under the following claims procedures section, the words 'you' and
'your' will mean a member of the group health plan of the Plan Sponsor. You become a claimant when
you make a request for a plan benefit or benefits in accordance with these claims procedures.
You and your covered dependents have the right to elect group health care benefits as offered by the
Plan Sponsor, and your and their rights will be determined under the plan's provisions and in
conjunction with the claims and appeals procedures outlined later in this section. Claims will also be
considered filed by you if communications and requests for benefits come from an individual that you
have designated as your authorized representative to act on your behalf with respect to a claim. In the
event that you designate an authorized representative to act on your behalf, the plan will send all
notifications, requests for further information, appeal decisions, and all other communications to your
authorized representative and provide you with a copy of all communications, unless you request
otherwise in writing.
An authorized representative may act on behalf of a claimant with respect to benefit claim or appeal
under these procedures. However, no person (including a treating health care professional) will be
recognized as an authorized representative until the plan receives an Designation of Authorized
Representative form signed by the claimant, except that for urgent care claims the plan shall, even in
the absence of a signed Designation of Authorized Representative form, recognize a health care
professional with knowledge of the claimant's medical condition (e.g., the treating physician or
practitioner) as the claimant's authorized representative unless the claimant provides specific written
direction otherwise.
A Designation of Authorized Representative form may be obtained from and completed forms must be
returned to:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extension 1009
cs@pacificsource.com
An assignment for purposes of payment (e.g., to a health professional) does not constitute appointment
of an authorized representative under these claims procedures. However, unless you have directed the
plan otherwise, claims submitted on your behalf by a health care professional will be considered a valid
claim if submitted pursuant to the guidelines outlined in these claim procedures.
Any reference in these claims procedures to the claimant is intended to include the authorized
representative of such claimant appointed in compliance with the above procedures.
For the purposes of the claims procedures section, any reference to 'days' will refer to calendar days,
not business days.
Questions about Your Claims
PacificSource is available to listen and help with any concerns or problems you may have with resolving
a claim. Because PacificSource wants you to be completely satisfied with the member services
assistance you receive, a process has been established for addressing your concerns and solving your
problems. If you have a concern regarding a person, a service, the quality of care, or you want to
inquire about what benefits are covered under the plan, please call PacificSource at (888) 977-9299
and explain your concern to one of their Customer Service Representatives. You may also express that
concern in writing. PacificSource will do their best to resolve the matter on your initial contact. If
PacificSource needs more time to review or investigate your concern, they will get back to you as soon
SingleSource Self-Insured 59
Exhibit'B'
as possible, but in any case within 30 days. They will not consider any of these communications to be a
'claim' for benefits. A formal claim for benefits must meet certain other standards which are described in
greater detail in these procedures.
Types of Claims
Pre-Service Claims -The plan subjects the receipt of benefits for some services or supplies to a
preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it
may in some cases be conducted on a post-service basis. Unless a response is needed sooner due to
the urgency of the situation, a pre-service preauthorization review will be completed and notification
made to you and your medical provider as soon as possible, generally within two working days, but no
later than 15 days within receipt of the request.
Urgent Care Claims - If the time period for making a non-urgent care determination could seriously
jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain
that cannot be adequately managed without the care or treatment that is proposed, a preauthorization
review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours
within receipt of the request.
Concurrent Care Review - A concurrent care decision occurs when a previously approved course of
treatment is reconsidered and reduced or denied, or where an extension is requested beyond the
initially approved period of time or number of treatments. Inpatient hospital or rehabilitative facilities,
skilled nursing facilities, intensive outpatient, and residential behavioral health care require concurrent
review for a benefit determination with regard to an appropriate length of stay or duration of service.
Benefit determinations will be made as soon as possible within receipt of all the information necessary
to make such a determination.
Post-Service Claims - A claim determination that involves only the potential payment of
reimbursement of the cost of medical care that has already been provided will be made as soon as
reasonably possible but no later than 30 days from the day after receiving the claim.
How to File a Claim
Most health care providers will file claims on your behalf. Electronically submitted claims are processed
most efficiently. If unable to file electronically, you, your health care provider, or an authorized
representative must file your claim using HCFA-1500 (revision 12/90 and later), U1392, or ADA (revision
12/90 and later) forms, or an itemized statement. These forms are available from your health care
provider or PacificSource.
A claim will be considered filed when it is received by PacificSource at the address listed below:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espanol (800) 624-6052, extension 1009
cs@pacificsource.com
The following information is required in order qualify your request for benefits as a properly submitted
claim:
• Plan member's name, member ID and current address;
• Patient's name, member ID and address if different from the member's;
• Provider's name; tax identification number, address, degree and signature;
• Date(s) of service(s);
• Place of service(s);
• Diagnostic Code;
• Procedure Codes (describes the treatment or services rendered);
• Assignment of Benefits, signed (if payment is to be made to the provider);
• Release of Information Statement, signed; and
SingleSource Self-Insured 60
Exhibit'B'
• Explanation of Benefits (EOB) information if another plan is the primary payer.
This plan also recognizes the following actions and submission of forms as claims:
• A request by you for benefits through preauthorization in cases where use of preauthorization is
required in order to obtain a particular benefit.
• Requests by your formally-designated authorized representative for preauthorization in cases
where use of preauthorization is required in order to obtain a particular benefit. The plan will take
reasonable steps to determine whether an individual claiming to be acting on your behalf is, in fact,
validly empowered to do so under the circumstances, and the plan will require that you complete
and file a form identifying any person you authorize to act on your behalf with respect to a claim.
However, when inquiries by a health care provider relate to payments due to the provider-rather
than due to you-under participating provider contracts (where the health care provider has no
recourse against you for the amounts) such inquiries by a health care provider will not be
considered 'claims' by the plan.
• Requests for benefits (in the case of a claim involving urgent care) by a health care provider with
knowledge of your medical condition. For urgent care claims, you are not required to complete a
form and formally designate a health care provider as your representative with respect to a claim.
Claims must be submitted individually for each claimant. Please do not staple claims together. Send
completed information to:
PacificSource Health Plans
PO Box 7068, Springfield OR 97475-0068
Phone (541) 684-5582 or (888) 977-9299
Espafiol (800) 624-6052, extension 1009
cs@pacificsou rce. com
If you have any questions regarding your eligibility, benefits or claims information, please call
PacificSource at: (888) 977-9299.
All claims for benefits must be submitted to the plan within 90 days of the date of service. If it is not
possible to submit a claim within 90 days, you should submit the claim as soon as possible. In some
cases the plan will accept the late claim. The plan, however, will not pay a claim that was submitted
more than one year after the date of service.
All submitted claims and appeals will fall into one of the categories described previously. The handling
of your initial claim or later appeal will be governed, in all respects, by the appropriate category of claim
or appeal, and each time your claim or appeal is examined, a new determination will be made regarding
the category into which the claim or appeal falls at that particular time.
Pre-service claims - Your plan subjects the receipt of benefits for some services or supplies to a
preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it
may in some case be conducted on a post-service basis. Unless a response is needed sooner due to
the urgency of the situation, a pre-service preauthorization review will be completed and notification
made to you and your medical provider as soon as possible, generally within two working days, but no
later than 15 days within receipt of the request.
Urgent care claims - If the time period for making a non-urgent care determination could seriously
jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain
that cannot be adequately managed without the care or treatment that is proposed, a preauthorization
review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours of
receipt of the request.
Concurrent care review- Inpatient hospital or rehabilitation facilities, skilled nursing facilities,
intensive outpatient, and residential behavioral healthcare require concurrent review for a benefit
determination with regard to an appropriate length of stay or duration of service. Benefit determinations
will be made as soon as possible but no later than one working day after receipt of all the information
necessary to make such a determination.
Post-service claims - A claim determination that involves only the payment of reimbursement of the
cost of medical care that has already been provided will be made as soon as reasonably passible but
no later than 30 days from the day after receiving the claim.
SingleSource Self-Insured 61
Exhibit'B'
Retrospective review -A claim for benefits for which the service or supply requires a preauthorization
review but was not submitted for review on a pre-service basis will be reviewed on a retrospective basis
within 30 working days after receipt of the information necessary to make a claim determination.
Extension of time - Despite the specified timeframes, nothing prevents the member from voluntarily
agreeing to extend the above timeframes. Unless additional information is needed to process your
claim, PacificSource will make every effort to meet the timeframes stated above. If a claim cannot be
paid within the stated timeframes because additional information is needed, PacificSource will
acknowledge receipt of the claim and explain why payment is delayed. If PacificSource does not
receive the necessary information within 15 days of the delay notice, PacificSource will either deny the
claim or notify you every 45 days while the claim remains under investigation. No extension is permitted
for urgent care claims.
Extension of time - Unless additional information is needed to process your claim, the plan will make
every effort to meet the timeframes stated above. If a claim cannot be paid within the stated timeframes
because additional information is needed, PacificSource will acknowledge receipt of the claim and
explain why payment is delayed. If they do not receive the necessary information within 15 days of the
delay notice, they will either deny the claim or notify you every 45 days while the claim remains under
investigation.
Adverse benefit determinations - Any denial, reduction or termination of, or failure to provide or
make a payment for a benefit based on:
• A determination that the member is not eligible to participate in the plan.
• A determination that the benefit is not covered by the plan.
• The imposing of limits, such as preexisting condition or source-of-injury exclusions.
• A determination that the benefit is experimental, investigational or not medically necessary or
medically appropriate.
An adverse benefit determination made to reduce or deny benefits applied for a pre-service, post-
service, or concurrent care basis may be appealed in accordance with the plan's appeals procedures
described later in this section.
Incomplete Claims
If any information needed to process a claim is missing, the claim shall be treated as an incomplete
claim.
Other Incomplete Claims - If a pre-service or post-service claim is incomplete, the plan may deny the
claim or may take an extension of time, as described above. If the plan takes an extension of time, the
extension notice shall include a description of the missing information and shall specify a timeframe, no
less than 45 days, in which the necessary information must be provided. The timeframe for deciding the
claim shall be suspended from the date the extension notice is received by the claimant until the date
the missing necessary information is provided to the plan. If the requested information is provided, the
plan shall decide the claim within the extension period specified in the extension notice. If the requested
information is not provided within the time specified, the claim may be decided without that information.
If you fail to follow the plan's filing procedures because your request for benefits does not: 1) identify
the patient; 2) note a specific medical condition or symptom; 3) describe a specific treatment, service,
or product for which approval is requested; or 4) is not sent to the correct address, you will not have
submitted a claim. You will be notified orally, and/or by written notification if requested by the claimant,
within 24 hours, that you have failed to follow the filing procedures, and you will be reminded of the
proper filing procedures.
Notification of Benefit Determination
The plan will pay the benefit according to plan provisions. This may mean that less than 100% of your
claim is payable by the plan. In each case where the plan pays benefits or determines that it is not
responsible for your medical claim, you will receive an Explanation of Benefits which will outline the
basis for the plan's payment. If your claim is denied or payable at a level less than outlined in this
Summary Plan Description, you are entitled to appeal the decision under the rules governing adverse
benefit determination.
SingleSource Self-Insured 62
Exhibit'B'
Adverse Benefit Determination
• Written notification will be provided to you of the plan's adverse benefit determination (as defined in
the How To File A Claim section above) and will include the following:
• Information sufficient to identify the claim involved, including the date of service, the health care
provider, and the claim amount (if applicable), as well as how to obtain the diagnosis code, the
treatment code, and the corresponding meanings of these codes.
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
• A description of any additional material or information necessary to perfect the claim and why such
information is necessary;
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, disclose either (a) an explanation of the
scientific or clinical judgment applying the terms of the plan to the claimant's medical
circumstances, or (b) a statement that such explanation will be provided at no charge upon request;
• In the case of an urgent care claim, an explanation of the expedited review methods available for
such claims; and
• A statement regarding the availability of, and contact information for, any applicable office of health
insurance consumer assistance or ombudsman.
Notification of the plan's adverse benefit determination on an urgent care claim may be provided orally,
but written notification shall be furnished not later than three days after the oral notice.
You may call the Third Party Administrator at (888) 977-9299 to discuss the adverse benefit
determination if you have concerns. You may also express those concerns in writing and if needed,
may submit additional information that you believe would clarify any of the circumstances that lead to
the adverse benefit determination. Third Party Administrator will not consider any of these questions or
clarifications to be a formal appeal unless you specifically state it as such. The process for filing a
formal appeal is listed below.
Your Right to Appeal
You have the right to appeal an adverse benefit determination under these claims procedures. If you
choose to appeal the plan's adverse benefit determination, your appeal will be governed by rules that
assure you a full and fair review.
If you are denied benefits based upon the plan's finding that you are/were ineligible for benefits, the
denial of benefits gives you the opportunity to appeal the plan's decision.
If the plan decides to reduce or terminate benefits for your previously-approved course of treatment, the
plan's decision will be treated as an adverse benefit determination, and the plan will provide you
reasonable advance notice of the reduction or termination to allow you to appeal the plan's decision
before the benefit reduction or termination takes place. If you decide to appeal the plan's decision, you
must follow the rules for appealing a plan's decision.
No lawsuit can be instituted until the claimant has exhausted the plan's internal and external claims
review and appeals procedures. No lawsuit can be instituted more than one year after the date of the
notice to the, claimant that a claim appeal has been denied.
Appealing an Initial Claim Determination - You must submit a written request to the plan within 180
days of receipt of an adverse benefit determination in order to initiate an appeal. An oral request for
review is acceptable for urgent care claims and may be made by calling the Third Party Administrator at
(888) 977-9299 and asking the plan to register your oral appeal.
SingleSource Self-Insured 63
Exhibit B'
When you appeal an adverse benefit determination, the plan will provide a full and fair review which will
include the following features:
• You will have the opportunity to submit written comments, documents, records, and other
information related to the claim.
• At your request (and free of charge), you will be provided with reasonable access to (and copies of)
all documents, records, and other information relevant to your claim for benefits. Included in this
category are any documents, records or other information in your claim file, whether or not those
materials were relied upon by the plan in making its adverse benefit determination. You also have
the right to review documentation showing that the plan followed its own internal processes for
ensuring appropriate decision making.
• The review of your claim will take into account all comments, documents and other information
without regard to whether such information was submitted or considered in the initial benefit
determination.
• Any appeal of an adverse benefit determination will not give deference to the initial decision on your
claim, and the review will be conducted by a designated plan representative who did not make the
original determination and does not report to the plan representative who made the original
determination.
• In deciding an appeal of any adverse benefit determination that is based on a medical judgment
(including determinations with regard to whether a particular treatment, drug, or other item is
experimental, investigational, or not medically necessary or medically appropriate), the designated
plan representative will consult with a health care professional who has appropriate training and
experience in the particular field of medicine involved in the medical judgment. This health care
professional will not be the same professional who was originally consulted in connection with the
adverse determination; neither will this health care professional report to the health care
professional who was consulted in connection with the adverse determination. The plan will uphold
the findings of the independent review in responding to the appeal.
• The plan will identify medical or vocational experts whose advice was obtained on behalf of the
plan in connection with an adverse benefit determination of your claim, whether or not that advice
was relied upon in making the benefit determination.
You must first follow this appeal process before taking any outside legal action. After you submit the
claim for appeal, the plan will make a decision on your appeal as follows:
Appeal of Urgent Care Claims - The plan's expedited appeal process for urgent care claims will allow
you to request (orally or in writing) an expedited appeal, after which, all necessary information, including
the plan's benefit determination on review, will be transmitted between the plan and you by telephone,
fax, or other expeditious method. You will be notified (in writing or electronically) of the benefit
determination as soon as possible, but not later than 72 hours after the plan receives the request for
review of the prior benefit determination. For urgent care claims you may also be able to request an
independent external review take place at the same time as you pursue the plan's internal appeal
process.
Appeal of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will be notified (in
writing or electronically) of the benefit determination within a reasonable period of time appropriate to
the medical circumstances, but not later than 30 days.
Appeal of Concurrent Care Claims - For concurrent care claims, you will be notified (in writing or
electronically) of the benefit determination with reasonable advance notice before the benefit reduction
or termination takes place.
Appeal of Post-Service Claims - For post-service claims, you will be notified (in writing or
electronically) of the benefit determination within a reasonable period of time, but not later than 60 days.
Denial of Claim on Appeal - If your appealed claim is denied, the plan will send you written or
electronic notification that explains why your appealed claim was denied and shall include the following:
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
SingleSource Self-Insured 64
Exhibit'B'
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request;
• If the determination involves scientific or clinical judgment, the plan will disclose either (a) an
explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's
medical circumstances, or (b) a statement that such explanation will be provided at no charge upon
request; and
• A statement indicating your right to receive, upon request (and free of charge), reasonable access
to (and copies of) all documents, records, and other information relevant to the determination.
Included in this category are any documents, records or other information in your claim file, whether
or not those materials were relied upon by the plan in making its adverse determination.
Additional Level of Review - If you are dissatisfied with the outcome of your appeal, you may request
an additional review. To initiate this review you should follow the same process required for an appeal.
You must submit a written request for additional review within 60 days following the receipt of the
appeal decision.
When you submit a request for additional review of an adverse benefit determination, the plan will
provide a full and fair review which will include the following features:
• You will have the opportunity to submit written comments, documents, records, and other
information related to the claim.
• At your request (and free of charge), you will be provided with reasonable access to (and copies of)
all documents, records, and other information relevant to your claim for benefits. Included in this
category are any documents, records or other information in your claim file, whether or not those
materials were relied upon by the plan in making its adverse benefit determination. You also have
the right to review documentation showing that the plan followed its own internal processes for
ensuring appropriate decision making.
• The review of your claim will take into account all comments, documents and other information
without regard to whether such information was submitted or considered in the initial adverse
benefit determination.
• Additional review will not afford deference to the appeal determination, and the review will be
conducted by a designated plan representative who did not make the original determination and
does not report to the plan representative who made the original determination.
• In deciding an appeal of any adverse benefit determination that is based on a medical judgment
(including determinations with regard to whether a particular treatment, drug, or other item is
experimental, investigational, or not medically necessary or medically appropriate), the designated
plan representative will consult with a health care professional who has appropriate training and
experience in the particular field of medicine involved in the medical judgment. This health care
professional will not be the same professional who was originally consulted in connection with the
adverse determination; neither will this health care professional report to the health care
professional who was consulted in connection with the adverse determination. The plan will uphold
the findings of the independent review in responding to the appeal.
• The plan will identify medical or vocational experts whose advice was obtained on behalf of the
plan in connection with an adverse benefit determination of your claim, whether or not that advice
was relied upon in making the benefit determination.
After you submit the claim for additional review, the plan will make a decision on your appeal as follows:
Additional Review of Urgent Care Claims - The plan's expedited additional review process for urgent
care claims will allow you to request (orally or in writing) an expedited review, after which, all necessary
information, including the plan's benefit determination on review, will be transmitted between the plan
and you by telephone, fax, or other expeditious method. You will be notified (in writing or electronically)
of the benefit determination as soon as possible, but not later than 72 hours after the plan receives the
request for the review.
Additional Review of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will
be notified (in writing or electronically) of the review outcome within a reasonable period of time
appropriate to the medical circumstances, but not later than 30 days.
SingleSource Self-Insured 65
Exhibit'B'
Additional Review of Concurrent Care Claims - For concurrent care claims, you will be notified (in
writing or electronically) of the review outcome with reasonable advance notice before the benefit
reduction or termination takes place.
Additional Review of Post-Service Claims - For post-service claims, you will be notified (in writing or
electronically) of the review outcome within a reasonable period of time, but not later than 60 days.
Denial of Claim after Additional Review - If after your request for additional review the claim is
denied, the plan will send you written or electronic notification that explains why the additional review
upheld the denial and shall include the following:
• A statement of the specific reason(s) for the decision;
• Reference(s) to the specific plan provision(s) on which the determination is based;
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making
the adverse determination or a statement that such information will be provided free of charge upon
request,
• If the determination involves scientific or clinical judgment, the plan will disclose either (a) an
explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's
medical circumstances, or (b) a statement that such explanation will be provided at no charge upon
request; and
• A statement indicating your right to receive, upon request (and free of charge), reasonable access
to (and copies of) all documents, records, and other information relevant to the determination.
Included in this category are any documents, records or other information in your claim file, whether
or not those materials were relied upon by the plan in making its adverse determination.
Independent External Review - You may have the right to have your case reviewed by an external
independent review organization. Only decisions that are based on issues related to medical necessity,
medical appropriateness, health care setting, level of care, or effectiveness of a covered benefit may be
appealed to an external independent review organization. The plan must contract with at least three
different independent external review organizations and must rotate between them on a random or
circulating basis.
Your request for an independent review must be made in writing to PacificSource within 180 days of the
date of the final internal adverse benefit determination. You may include additional written information,
which will be included with the documents PacificSource provides to the independent review
organization.
A final decision made by an independent review organization is binding on the Plan Sponsor. This
decision is also binding on you, except to the extent other remedies are available under state or federal
law.
In certain instances you may be able to request an expedited review process, such as when the
timeframe for completion of the internal appeals process would seriously jeopardize the life or health of
the claimant or their ability to regain maximum function, or if the final adverse benefit determination
concerns an admission, availability of care, continued stay or health care service for which the claimant
received emergency services, but has not been discharged from a facility.
Resources For Information And Assistance
Assistance in Other Languages
Members who do not speak English may contact PacificSource's Customer Service Department for
assistance. They can usually arrange for a multilingual staff member or interpreter to speak with them in
their native language.
Information Available from PacificSource
PacificSource makes the following written information available to you free of charge. You may contact
their Customer Service Department by phone, mail, or email to request any of the following:
• A directory of participating healthcare providers under your plan
SingleSource Self-Insured 66
Exhibit'B'
• Information about PacificSource's drug formulary
• A copy of PacificSource's annual report on complaints and appeals
• A description (consistent with risk-sharing information required by the Centers for Medicare and
Medicaid Services, formerly known as Health Care Financing Administration) of any risk-sharing
arrangements PacificSource has with providers
• A description of PacificSource's efforts to monitor and improve the quality of health services
• Information about how PacificSource checks the credentials of PacificSource's network providers
and how you can obtain the names and qualifications of your healthcare providers
• Information about PacificSource's preauthorization procedures
• Information about any healthcare plan offered by the Plan Sponsor
Information Available from the Oregon Insurance Division
The following consumer information is available from the Oregon Insurance Division:
• The results of all publicly available accreditation surveys
• A summary of PacificSource's health promotion and disease prevention activities
• Samples of the written summaries delivered to PacificSource policyholders
• An annual summary of grievances and appeals against PacificSource
• An annual summary of PacificSource's quality assessment activities
• An annual summary of the scope of PacificSource's provider network and accessibility of
healthcare services
You can request this information by contacting the Oregon Insurance Division by writing to the Oregon
Insurance Division, Consumer Advocacy Unit, PO Box 14489, Salem, OR 97309-0405 or by phone at
(503) 947-7984, or the toll-free message line at (888) 877-4894, on the Internet at
http://insurance.oregon.gov/consumer/consumer.html, or by email at cp.ins@state.or.us.
Plan Sponsor's Discretionary Authority; Standard of Review
The Plan Sponsor is the sole fiduciary of the plan, and exercises all discretionary authority and control
over the administration of the plan and the management and disposition of plan assets. Benefits under
the plan will be paid only if the Plan Sponsor decides, in its discretion, that the member or beneficiary is
entitled to such benefits. Any construction of the terms of any plan document and any determination of
fact adopted by the Plan Sponsor shall be final and legally binding on the parties. A court of law or
arbitrator reviewing any fiduciary's decision, including one relating the plan interpretation or a benefit
claim, must consider only the documents, testimony and other evidence that were presented to the
fiduciary at the time the fiduciary made the decision. In addition, the court or arbitrator must use the
'arbitrary and capricious' standard of review. That is, the fiduciary's determination can be reversed only
if it was made in bad faith, is not supported by substantial evidence or is erroneous as to a question of
law.
The Plan Sponsor may hire someone to perform claims processing and other specified services in
relation to the plan. Any such contractor will not be a fiduciary of the plan and will not exercise any of
the discretionary authority and responsibility granted to the Plan Sponsor, as described above.
Coordination of Benefits
Coordinating with Other Group Health Plans - When benefits are coordinated, one plan pays
benefits first (the 'primary coverage') and the other plan pays benefits second (the 'secondary
coverage').
When you and/or your dependents are covered under more than one group health plan, the combined
benefits payable by this plan and all other group plans will not exceed 100% of the eligible expense
incurred by the individual. The plan assuming primary payer status will determine benefits first without
regard to benefits provided under any other group health plan.
SingleSource Self-Insured 67
Exhibit'B'
Note: If your primary and secondary coverage both include a deductible, you will be required to satisfy
each of those deductibles before benefits will be paid.
There are two types of Coordination of Benefits -'True' Coordination of Benefits and Non-Duplicating
Coordination of Benefits (also called Integration of Benefits.) See the Medical Benefit Summary to
determine if your plan offers True Coordination of Benefits or Non-Duplicating/Integration of Benefits.
For True Coordination of Benefits, the primary plan will pay benefits first, subject to any deductibles,
copayments and coinsurance. The remaining balance will be passed on to the secondary payer. When
this plan is the secondary payer, the balance of eligible expenses will be applied as if it was a new
claim under this plan. Deductibles, copayments and coinsurance relevant to this plan will be subtracted
from the amount before paying the remainder.
For Non-Duplicating Coordination of Benefits/Integration of Benefits, the primary plan will pay
benefits first, subject to any deductibles, copayments and coinsurance. The remaining balance will be
passed on to the secondary payer. When this plan is the secondary payer, it will reimburse the balance
of remaining eligible expenses, not to exceed normal plan liability if this plan had been primary. This
means that if the primary payer has already paid as much as or more than this plan would have paid
had this plan been primary, there will be no additional payment made.
Government Programs and Other Group Health Plans -The term group health plan, as it relates to
coordination of benefits, includes the government programs Medicare, Medicaid and TriCare. The
regulations governing these programs take precedence over the determination of benefits under this
plan. For example, in determining the benefits payable under the plan, the plan will not take into
account the fact that you or any eligible dependent(s) are eligible for or receive benefits under a
Medicaid plan.
The term group health plan also includes all group insurance and group subscriber contracts, such as
union welfare plans.
Order of Payment When Coordinating with Other Group Health Plans
• If the other plan does not include 'coordination of benefits,' that plan is primary and this plan is
secondary.
• If you are covered as an employee on one plan and a dependent on another, your Plan Sponsors
plan is primary.
• When a child is covered under both parents' policies and the parents are either married or are living
together (regardless of whether or not they have ever been married):
The parent whose birthday falls first in a benefit year has the primary plan; or
- If both parents have the same birthday, the parent who has been covered the longest has the
primary plan.
• When a child is covered under both parents' plans and the parents are divorced, separated, or not
living together (regardless of whether or not they have ever been married):
- If a court order specifies that one parent is responsible for the child's healthcare expenses,
the mandated parent's coverage is primary regardless of custody.
- If a court order specifies that both parents are responsible for the child's healthcare
expenses, the parent whose birthday falls first in a benefit year has the primary plan. If both
parents have the same birthday, the parent who has been covered the longest has the
primary plan.
- If a court order specifies that both parents have joint custody without specifying that one
parent has responsibility for the child's healthcare expenses, the parent whose birthday falls
first in a benefit year has the primary plan. If both parents have the same birthday, the parent
who has been covered the longest has the primary plan.
- If there is no court order, the order of benefits for the child are as follows:
o The custodial parent's coverage is primary;
o The spouse of the custodial parent's coverage pays second;
o The natural parent without custody's coverage pays third; and
SingleSource Self-Insured 68
Exhibit'B'
o The spouse of the natural parent without custody's coverage pays fourth.
• If a plan covers you as an active employee or a dependent of an active employee, that plan is
primary. Another plan covering you as inactive, laid off, or retired is secondary.
• When this plan covers you or your dependent pursuant to COBRA or under a right of continuation
pursuant to other federal law, the plan covering you or your dependent as an employee, member,
subscriber, or retiree or covering you or your dependent as a dependent of an employee, member,
subscriber or retiree is the primary plan and this plan's coverage is the secondary plan.
• If none of these rules apply, the coverage that has been in place longest is primary.
Most insurers or administrators send you an explanation of benefits, or EOB, when they pay a claim. If
your other plan's coverage is primary, send PacificSource the other plan's EOB with your original bill
and they will process your claim. If you receive more than you should when your benefits are
coordinated, you will be expected to repay any over-payment to the plan.
Right to Make Payments to Other Organizations - Whenever payments, which should have been
made by this plan, have been made by any other plan(s), this plan has the right to pay the other plan(s)
any amount necessary to satisfy the terms of this coordination of benefits provision. Amounts paid will
be considered benefits paid under this plan and, to the extent of such payments, the plan will be fully
released from any liability regarding the person for whom payment was made.
Automobile Insurance - This plan provides benefits relating to medical expenses incurred as a result
of an automobile accident on a secondary basis only. Benefits payable under this plan will be
coordinated with and secondary to benefits provided or required by any no-fault automobile insurance
statute, whether or not a no-fault policy is in effect, and/or any other automobile insurance.
Any benefits provided by this plan will be subject to the plan's reimbursement and/or subrogation
provisions.
OTHER IMPORTANT PLAN PROVISIONS
Assignment of Benefits
All benefits payable by the plan are automatically assigned to the provider of services or supplies,
unless evidence of previous payment is submitted with the claim form. However, the plan reserves the
right to reimburse the member, the provider, or both jointly. Payments made in accordance with an
assignment are made in good faith and release the plan's obligation to the extent of the payment.
Payments will also be made in accordance with any assignment of rights required by a state Medicaid
plan.
Members are expressly prohibited from assigning any right to payment of benefits under a Benefit
Program, including this plan. No attempts at assignment of any such expenses under a Benefit
Program will be recognized. Except as may be expressly prescribed in an agreement to which the Plan
Sponsor is a party, nothing contained in any written designation of coverage under a Benefit Program
will make the Benefit Program, or the Plan Sponsoror any other employer, liable to any third-party to
whom a member may be liable for medical care, treatment or services.
Proof of Loss
The Plan Sponsor has the right to require a claimant to undergo physical or psychological examinations
relating to the claimant's illness, injury or condition as often as the Plan Sponsor deems reasonably
necessary while the claim for benefits is pending. The Plan Sponsor also has the right to require an
autopsy in case of death (where not prohibited by law).
No Verbal Modifications of Plan Provisions
No verbal statement made by anyone involved in administering this plan can waive any of the terms or
conditions of this plan or prevent the Plan Sponsorfrom enforcing any provision of this plan. Waivers
are valid only if they are contained in a written instrument signed by an authorized individual on behalf
of the Plan Sponsor. Any such written waiver will be valid only as to the specific plan, term or condition
set forth in the written instrument. Unless specifically stated otherwise, a written waiver will be valid only
for the specific claim involved at the time, and will not be a continuing waiver of the term or condition in
the future.
SingleSource Self-Insured 69
Exhibit'B'
Reimbursement to the Plan
This section applies whenever another party (including your own insurer under an automobile or other
policy) is legally responsible or agrees to compensate you or your dependent, by settlement, verdict or
otherwise, for an illness or injury. In that case, you or your dependent (or the legal representatives,
estate or heirs of either you or your dependent), must promptly reimburse the plan for any benefits it
paid relating to that illness or injury, up to the full amount of the compensation received from the other
party (regardless of how that compensation may be characterized and regardless of whether you or
your dependent have been made whole). If the plan has not yet paid benefits relating to that illness or
injury, the plan may reduce or deny future benefits on the basis of the compensation received by you or
your dependent.
Benefits relating to such illness or injury will not be payable by the plan until you sign and return a
statement, provided by the plan, acknowledging your obligation to reimburse the plan under this
provision. That obligation will arise upon the payment of any plan benefits relating to the illness or
injury, whether or not you sign such a statement.
You or your dependent must cooperate with the plan and its authorized representatives, and must sign
and deliver such documents as the plan or its agents reasonably request to protect the plan's right of
reimbursement. You or your dependent must also provide any relevant information and take such
actions as the plan or its agents reasonably request to assist the plan in making a full recovery of the
reasonable value of the benefits provided. You or your dependent must not take any action that
prejudices the plan's right of reimbursement.
In order to secure the rights of the plan under this section, you or your dependent hereby: (1) grant to
the plan a first priority lien against the proceeds of any such settlement, verdict or other amounts
received by you or your dependent; and (2) assign to the plan any benefits you or your dependent may
have under any automobile policy or other coverage, to the extent of the plan's claim for
reimbursement.
The reimbursement required under this provision will not be reduced to reflect any costs or attorneys'
fees incurred in obtaining compensation unless separately agreed to, in writing, by the Plan Sponsor, in
the exercise of its sole discretion.
This plan expressly disavows and repudiates the make whole doctrine, which, if applicable, would
prevent the plan from receiving a recovery unless a member has been 'made whole' with regard to
illness or injury that is the responsibility of a third party. This plan also expressly disavows and
repudiates the common fund doctrine, which, if applicable, would require the plan to pay a portion of the
attorney fees and costs expended in obtaining a recovery. These doctrines have no application to this
plan, since the plan's recovery rights apply to the first dollars payable by a third party.
Subrogation
This section applies whenever another party (including your own insurer under an automobile or other
policy) is legally responsible or agrees to compensate you or your dependent for you or your
dependent's illness or injury and the plan has paid benefits related to that illness or injury.
The plan is subrogated to all of the rights of you or your dependent against any party liable for you or
your dependent's illness or injury to the extent of the reasonable value of the benefits provided to you or
your dependent under the plan. The plan may assert this right independently of you or your dependent.
You and your dependent are obligated to cooperate with the plan and its authorized representatives in
order to protect the plan's subrogation rights. Cooperation means providing the plan or its agents with
anytrelevant information requested by them, signing and delivering such documents as the plan or its
agents reasonably request to secure the plan's subrogation claim, and obtaining the consent of the plan
or its agents before releasing any party from liability for payment of medical expenses.
If you or your dependent enters into litigation or settlement negotiations regarding the obligations of
other parties, you or your dependent must not prejudice, in any way, the subrogation rights of the plan
under this section.
SingleSource Self-Insured 70
Exhibit'B'
The costs of legal representation of the plan in matters related to subrogation will be borne solely by the
plan. The costs of legal representation of you or your dependent must be borne solely by you or your
dependent.
Recovery of Excess Payments
Whenever payments have been made in excess of the amount necessary to satisfy the provisions of
this plan, or were made in error by the plan, the plan has the right to recover these payments from any
individual (including yourself), insurance company or other organization to whom the payments were
made or to withhold payment, if necessary, on future benefits until the overpayment is recovered. If
excess or erroneous payments were made for services rendered to your dependent(s), the plan has the
right to withhold payment on your future benefits until the overpayment is recovered.
Further, whenever payments have been made based on fraudulent information provided by you, the
plan will exercise all available legal rights, including its right to withhold payment on future benefits, until
the overpayment is recovered.
In the same manner, if the plan applies medical expenses to the plan deductible that would not
otherwise be reimbursable under the terms of this policy; the plan may deduct a like amount from the
accumulated deductible amounts and/or recover payment of medical expenses that would have
otherwise been applied to the deductible. The fact that a medical expense was applied to the plan's
deductible, or that a drug was provided under the plan's prescription drug program, does not in itself
create an eligible expense or infer that benefits will continue to be provided for an otherwise excluded
condition.
Right To Receive and Release Necessary Information
The plan may, without the consent of or notice to any person, release to or obtain from any organization
or person, information needed to implement plan provisions, including medical information. When you
request benefits, you must either furnish or authorize the release of all the information required to
implement plan provisions. Your failure to fully cooperate will result in a denial of the requested benefits
and the plan will have no further liability for such benefits.
Under normal conditions, benefits are payable to the provider of services or supplies, unless evidence
of previous payment is submitted with the claim form. If conditions exist under which a valid release or
assignment cannot be obtained, the plan may make payment to any individual or organization that has
assumed the care or principal support for you and is equitably entitled to payment. The plan must make
payments to your separated/divorced spouse, state child support agencies or Medicaid agencies if
required by a qualified medical child support order (QMCSO) or state Medicaid law.
The plan may also honor benefit assignments made prior to your death in relation to remaining benefits
payable by the plan.
Any payment made by the plan in accordance with this provision will fully release the plan of its liability
to you.
Reliance on Documents and Information
Information required by the Plan Sponsor or PacificSource may be provided in any form or document
that the Plan Sponsor and PacificSource considers acceptable and reliable. The Plan Sponsor and
PacificSource relies on the information provided by you and others when evaluating coverage and
benefits under the plan. All such information, therefore, must be accurate, truthful and complete. The
Plan Sponsor and PacificSource is entitled to conclusively rely upon, and will be protected for any
action taker in good faith in relying upon, any information provided to the Plan Sponsor or
PacificSource. In addition, any fraudulent statement, omission or concealment of facts,
misrepresentation, or incorrect information may result in the denial of the claim, cancellation or
rescission of coverage, or any other legal remedy available to the plan.
No Waiver
The failure of the Plan Sponsorto enforce strictly any term or provision of this plan will not be construed
as a waiver of such term or provision. The Plan Sponsor reserves the right to enforce strictly any term
or provision of this plan at any time.
SingleSource Self-Insured 71
Exhibit'B'
Physician/Patient Relationship
This plan is not intended to disturb the physician/patient relationship. Physicians, practitioners and other
health care providers are not agents or delegates of the Plan Sponsor, or the Third Party Administrator.
Nothing contained in this plan will require you or your dependent to commence or continue medical
treatment by a particular provider. Further, nothing in this plan will limit or otherwise restrict a physician
or practitioner's judgment with respect to the physician or practitioner's ultimate responsibility for patient
care in the provision of medical services to you or your dependent.
Plan not responsible for Quality of Health Care
You and your enrolled dependents have the right to select your health care provider. Neither the plan,
your Plan Sponsor, nor Third Party Administrator is responsible for the quality of care received and
cannot be held liable for any claim or damages connected with injuries suffered while receiving health
services or supplies.
Plan is not a Contract of Employment
Nothing contained in this plan will be construed as a contract or condition of employment between the
Plan Sponsor and any employee. All employees are subject to discharge to the same extent as if this
plan had never been adopted.
Right to Amend or Terminate Plan
Plan Sponsor reserves the right to amend, modify or terminate the plan in any manner, for any reason,
at any time.
If changes occur, your Plan Sponsor will notify you of changes to your plan.
If your health plan terminates and your Plan Sponsor does not replace the coverage with another group
policy, your Plan Sponsor is required by law to advise you in writing of the termination. When this plan
terminates, your Plan Sponsor will notify you about any available options for you to continue your
coverage.
The Plan Sponsor may pay your medical claims if a workers' compensation claim has been denied on
the basis that the illness or injury is not work related, and the denial is under appeal. But before
PacificSource does that, you must sign a written agreement to reimburse the Plan Sponsor any money
you recover from the workers' compensation coverage.
Rescissions
The Plan Sponsor or PacificSource may not rescind the coverage of a member unless the member, or
person seeking coverage on behalf of the member, performs an act, practice or omission that
constitutes fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms
of this plan and the Plan Sponsor or PacificSource gives the member a 30-day prior written notice.
PacificSource may not rescind the policyholder's group health benefit plan unless the policyholder, or
representative of the policyholder, performs an act, practice or omission that constitutes fraud or makes
an intentional misrepresentation of a material fact as prohibited by the terms of this plan and
PacificSource gives a 30-day prior written notice to all member covered under the plan. Rescissions do
not include a cancellation or discontinuance of coverage that is prospective or to the extent it is
attributable to a failure to timely pay required contributions towards the cost of coverage.
Applicable Law
This is a self-insured benefit plan. As such, Federal law preempts State law and jurisdiction. To the
extent not preempted by federal law, the laws of the state of Oregon shall apply.
PRIVACY AND CONFIDENTIALITY
This notice is intended to bring the City of Ashland Employee Benefit Plan into compliance with the
requirements of Section 164.504(f) of the Health Insurance Portability and Accountability Act of 1996
and its implementing regulations, 45 C.F.R. parts 160 through 164 (the'HIPAA Privacy Rule') by
SingleSource Self-Insured 72
Exhibit'B'
establishing the conditions under which the Plan Sponsorwill receive, use and/or disclose protected
health information.
Permitted Disclosures of Protected Health Information to the Plan Sponsor
Subject to the conditions of the 'No Disclosure of Protected Health Information to the Employer Without
Certification by Employer' and 'Conditions of Disclosure of Protected Health Information to the
Employer', the plan (and any third party administrator or business associate acting on behalf of the
plan) may disclose individuals' protected health information to the Plan Sponsorfor the Plan Sponsoror
PacificSource to carry out plan administration functions. The plan (and any third party administrator or
business associate acting on behalf of the plan) may not disclose individuals' protected health
information to the Plan Sponsor for employment-related actions and decisions or in connection with any
other benefit or employee benefit plan of the Plan Sponsor.
No Disclosure of Protected Health Information to the Plan Sponsorwithout Certification by Plan
Sponsor
Except as provided below in 'Disclosures of Summary Health Information and Enroll ment/Disenrollment
Information to the Employer,' with respect to the plan's disclosure of summary health information and
enrollment/disenrollment information, the plan will not disclose protected health information to any
employee of the Plan Sponsor.
Conditions of Disclosure of Protected Health Information to the Plan Sponsor
The Plan Sponsor certifies that the plan has been amended to incorporate this section and agrees to
the following restrictions and conditions of receiving protected health information (other than summary
health information or enrollment/disenrollment information as explained in 'Disclosures of Summary
Health Information and Enrollment/Disenrollment Information to the Plan Sponsor below). The Plan
Sponsorshall:
• Not use or further disclose the protected health information other than as permitted or required
herein or as required by law.
• Ensure that any agent(s), including a subcontractor, to whom it provides protected health
information received from the plan agrees to the same restrictions and conditions that apply to the
Plan Sponsor with respect to such protected health information.
• Not use or disclose protected health information for employment-related actions and decisions or in
connection with any other benefit or employee benefit plan of the Plan Sponsor.
• Report to the plan any use or disclosure of protected health information that is inconsistent with the
uses or disclosures provided for of which the Plan Sponsor becomes aware.
• Make available protected health information to comply with an individual's right to access protected
health information in accordance with 45 C.F.R. Section 164.524.
• Make available protected health information for amendment and incorporate any amendments to
protected health information in accordance with 45 C.F.R. Section 164.526.
• Make available the information required to provide an accounting of disclosures in accordance with
45 C.F.R. §164.528.
• Make its internal practices, books and records relating to the use and disclosure of protected health
information received from the plan available to the Secretary of the Department of Health and
Human Services for purposes of determining compliance by the plan with the HIPAA Privacy Rule.
• If feasible, return or destroy all protected health information received from the plan that the Plan
Sponsor still maintains in any form and retain no copies 6f such information when no longer needed
for the purpose for which disclosure was made, except that, if such return or destruction is not
feasible, the Plan Sponsorwill limit further uses and disclosures to those purposes that make the
return or destruction of the information infeasible.
• Ensure that the required adequate separation, described in 'Required Separation Between the Plan
and the Plan Sponsor' below, is established and maintained.
SingleSource Self-Insured 73
Exhibit 'B'
Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the
Plan Sponsor
• The plan (or a third party administrator of the plan) may disclose summary health information to the
Plan Sponsorwithout the need to comply with the conditions and restrictions of 'No Disclosure of
Protected Health Information to the Plan Sponsor Without Certification by Plan Sponsor' and
'Conditions of Disclosure of Protected Health Information to the Plan Sponsor, if the Plan Sponsor
requests the summary health information for the purpose of:
- Obtaining premium bids from health plans (including health insurance issuers) for providing
health insurance coverage under the plan; or
- Modifying, amending, or terminating the plan
• The plan (or a third party administrator of the plan) may disclose information on whether the
individual is participating in the group health plan, or is enrolled in or has disenrolled from the plan
without the need to comply with the conditions and restrictions of 'No Disclosure of Protected
Health Information to the Plan Sponsor Without Certification by Plan Sponsor' and 'Conditions of
Disclosure of Protected Health Information to the Plan Sponsor'
Required Separation between the Plan and the Plan Sponsor
• The following classes of employees or other persons under the control of the Plan Sponsor will
have access to protected health information received from the plan (or from a health insurance
issuer with respect to the plan):
- Human Resources
• No other persons shall have access to protected health information. The listed classes of
employees or other persons under the control of the Plan Sponsorwill have access to protected
health information solely to perform the plan administration functions that the Plan Sponsor
performs for the plan. They will be subject to disciplinary action and/or sanctions (including
termination of employment or affiliation with the Plan Sponsor) for any use or disclosure of
protected health information in violation of the provisions of this plan.
DEFINITIONS
Wherever used in this plan, the following definitions apply to the terms listed below, and the masculine
includes the feminine and the singular includes the plural. For the purpose of this plan, 'employee'
includes the Plan Sponsorwhen covered by this plan. Other terms are defined where they are first used
in the text.
Abutment is a tooth used to support a prosthetic device (bridges, partials or overdentures). With an
implant, an abutment is a device placed on the implant that supports the implant crown.
Accident means an unforeseen or unexpected event causing injury that requires medical attention.
Actively at work or active employment means that an employee is performing in the customary
manner all of the regular duties of his/her occupation with the Plan Sponsor, either at one of the Plan
Sponsor's regular places of business or at some location to which the Plan Sponsor's business requires
the employee to travel to perform his/her regular duties assigned by the Plan Sponsor. An employee is
also considered to be actively at work on each day of a regular paid vacation or non-work day, but only
if the employee is performing in the customary manner all of the regular duties of the employee's
occupation with the Plan Sponsor on the immediately preceding regularly scheduled workday.
Advanced diagnostic imaging means diagnostic examinations using CT scans, MRIs, PET scans,
CATH labs, and nuclear cardiology studies.
Adverse benefit determination means a denial, reduction; or termination of a healthcare item or
service, or a failure or refusal to provide or to make a payment in whole or in part for a healthcare item
or service, that is based on the Plan Sponsor's or PacificSource's:
• Denial of eligibility for or termination of enrollment in a health benefit plan;
• Rescission or cancellation of a policy or coverage;
• Imposition of a source-of-injury exclusion, network exclusion, annual benefit limit or other limitation
on otherwise covered items or services;
SingleSource Self-Insured 74
Exhibit'B'
• Determination that a healthcare item or service is experimental, investigational, or not medically
necessary, effective, or appropriate; or
• Determination that a course or plan of treatment that a member is undergoing it an active course of
treatment for purposes of continuity of care under ORS 743.854.
Advantage Essential Network is the exclusive provider network that provides dental care to members
under this plan.
Allowable fee is the dollar amount established by the plan for reimbursement of charges for specific
services or supplies provided by nonparticipating providers. The plan uses several sources to
determine the allowable amount. Depending on the service or supply and the geographical area in
which it is provided, the allowable amount may be based on data collected from the Centers for
Medicare and Medicaid Services (CMS), Viant Health Payment Solutions, other nationally recognized
databases, or PacificSource.
Where the provider network is deemed adequate, the allowable fee for professional services is based
on PacificSource's standard participating provider reimbursement rate or a contracted reimbursement
rate. Outside the PacificSource service area and in areas where the participating provider network is
not deemed adequate, the allowable fee is based on the usual, customary, and reasonable charge
(UCR) at the 85th percentile. UCR is based on data collected for a geographic area. Provider charges
for each type of service are collected and ranked from lowest to highest. Charges at the 85th position in
the ranking are considered to be the 85th percentile.
Alveolectomy is the removal of bone from the socket of a tooth.
Amalgam is a silver-colored material used in restoring teeth.
Ambulatory surgical center means a facility licensed by the appropriate state or federal agency to
perform surgical procedures on an outpatient basis.
Ancillary Services means service rendered in connection with Inpatient or Outpatient care in a
Hospital or in connection with a medical emergency, such as assistant surgeon, anesthesiology,
ambulance, pathology and radiology.
Approved clinical trials are Phase I, II, III, or IV clinical trials for the prevention, detection, or treatment
of cancer or another life-threatening condition or disease.
Authorized representative is an individual who by law or by the contest of a person may act on behalf
of the person.
Benefit year means the 12-month period beginning on each January 1 and ending on the next
December 31.
Cardiac rehabilitation refers to a comprehensive program that generally involves medical evaluation,
prescribed exercise, and cardiac risk factor modification. Education, counseling, and behavioral
interventions are sometimes used as well. Phase I refers to inpatient services that typically occur during
hospitalization for heart attack or heart surgery. Phase II refers to a short-term outpatient program,
usually involving ECG-monitored exercise. Phase III refers to a long-term program, usually at home or
in a community-based facility, with little or no ECG monitoring.
Cast restoration includes crowns, inlays, onlays, and other restorations made to ft a patient's tooth
that are made at a laboratory and cemented onto the tooth.
Certificate of Creditable Coverage means a certificate or other documentation that shows previous
health insurance coverage for a member and can be used to reduce the length of any pre-existing
condition exclusions under a plan. See Creditable coverage.
Chemical dependency means the addictive relationship with any drug or alcohol characterized by
either a physical or psychological relationship, or both, that interferes with the individual's social,
psychological, or physical adjustment to common problems on a recurring basis. Chemical dependency
does not include addiction to, or dependency on, tobacco products or foods.
Claims Administrator means the organization selected by the City of Ashland to provide claims
processing and adjudication under their plans. The Claims Administrator for their medical, vision and
pharmacy coverage is PacificSource.
Composite resin is a tooth-colored material used in restoring teeth.
Contracted amount means the amount that participating providers have contracted to accept as
payment in full for covered expenses under the plan.
SingleSource Self-Insured 75
Exhibit 'B'
Copayment or coinsurance is the out-of-pocket amount a member is required to pay to a provider.
Creditable coverage means a member's prior health coverage that meets the following criteria:
• There was no more than a 63-day break between the last day of coverage under the previous
policy and the first day of coverage under this policy. The 63-day limit excludes the Plan Sponsor's
eligibility waiting period.
• The prior coverage was one of the following types of insurance: group coverage (including Federal
Employee Health Benefit Plans and Peace Corps), individual coverage (including student health
plans), Medicaid, Medicare, TRICARE, Indian Health Service or tribal organization coverage, state
high-risk pool coverage, and public health plans.
Curettage is the scraping and cleaning of the walls of a real or potential space, such as a gingival
pocket or bone, to remove pathological material.
Custodial Care means non-medical care that is primarily to assist with activities of daily living, whether
or not the care is administered by a licensed provider.
Deductible means the portion of the healthcare expense that must be paid by the member before the
benefits of this plan are applied.
Dental emergency means the sudden and unexpected onset of a condition, or exacerbation of an
existing condition, requiring necessary care to control pain, swelling or bleeding in or around the teeth
and gums. Such emergency care must be provided within 48 hours following the onset of the
emergency and includes treatment for acute infection, pain, swelling, bleeding, or injury to natural teeth
and oral structures. The emergency care does not include follow-up care such as, but not limited to,
crowns, root canal therapy, or prosthetic benefits.
Dentist means a person acting within the scope of their license, holding the degree of Doctor of
Medicine (M.D.), Doctor of Dental Surgery (D.D.S.), or Doctor of Dental Medicine (D.M.D.), and who is
legally entitled to practice dentistry in all its branches under the laws of the state or jurisdiction where
the services are rendered.
Durable medical equipment means equipment that can withstand repeated use; is primarily and
customarily used to serve a medical purpose rather than convenience or comfort; is generally not useful
to a person in the absence of an illness or injury; is appropriate for use in the home; and is prescribed
by a physician. Examples of durable medical equipment include but are not limited to hospital beds,
wheelchairs, crutches, canes, walkers, nebulizers, commodes, suction machines, traction equipment,
respirators, TENS units, and hearing aids.
Durable medical equipment supplier means a PacificSource contracted provider or a provider that
satisfies the criteria in the Medicare Qualify Standards for Suppliers of Durable Medical Equipment,
Prosthetics, Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description.
Elective surgery or procedure refers to a surgery or procedure for a condition that does not require
immediate attention and for which a delay would not have a substantial likelihood of adversely affecting
the health of the patient.
Eligible dental provider means a physician, dentist, oral surgeon, endodontist, orthodontist,
periodontist, or pedodontist. Eligible provider may also include a denturist or dental hygienist to the
extent that he/she operates within the scope of their license.
Emergency medical condition means a medical condition:
• That manifests itself by acute symptoms of sufficient severity, including severe pain that a prudent
layperson possessing an average knowledge of health and medicine would reasonably expect that
failure to receive immediate medical attention would:
- Place the health of a person, or an unborn child in the case of a pregnant woman, in serious
jeopardy;
- Result in serious impairment to bodily functions; or
- Result in serious dysfunction of any bodily organ or part; or
• With respect to a pregnant woman who is having contractions, for which there is inadequate time to
affect a safe transfer to another hospital before delivery or for which a transfer may pose a threat to
the health or safety of the woman or the unborn child.
Emergency medical screening exam means the medical history, examination, ancillary tests, and
medical determinations required to ascertain the nature and extent of an emergency medical condition.
SingleSource Self-Insured 76
Exhibit'B'
Emergency services means, with respect to an emergency medical condition:
• An emergency medical screening exam that is within the capability of the emergency department of
a hospital, including ancillary services routinely available to the emergency department to evaluate
such emergency medical condition, and
• Such further medical examination and treatment as are required under 42 U.S.C. 1395dd to
stabilize the patient to the extent the examination and treatment are within the capability of the staff
and facilities available at a hospital.
Employee means any individual employed by a Plan Sponsor.
Endorsement is a written attachment that alters and supersedes any of the terms or conditions set
forth in this contract.
Enrollee means an employee, dependent of the employee, or individual otherwise eligible and enrolled
for coverage under this plan. In this policy, enrollee is referred to as subscriber or member.
Essential health benefits are services defined as such by the Secretary of the U.S. Department of
Health and Human Services. Essential health benefits fall into the following categories:
• Ambulatory patient services,
• Emergency services;
• Hospitalization;
• Maternity and newborn care;
• Mental health and substance use disorder services, including behavioral health treatment;
• Prescription drugs;
• Rehabilitative and habilitative services and devices;
• Laboratory services,
• Preventive and wellness services and chronic disease management; and
• Pediatric services, including oral and vision care.
Exclusion period means a period during which specified conditions, treatments or services are
excluded from coverage.
Experimental or investigational procedures means services, supplies, protocols, procedures,
devices, chemotherapy, drugs or medicines, or the use thereof, that are experimental or investigational
for the diagnosis and treatment of illness or injury.
• Experimental or investigational services and supplies include, but are not limited to, services,
supplies, procedures, devices, chemotherapy, drugs or medicines, or the use thereof, which at the
time they are rendered and for the purpose and in the manner they are being used:
- Have not yet received full U.S. government agency required approval (e.g., FDA) for other
than experimental, investigational, or clinical testing;
- Are not of generally accepted medical practice in the state of Oregon or as determined by
PacificSource in consultation with medical advisors, medical associations, and/or technology
resources;
- Are not approved for reimbursement by the Centers for Medicare and Medicaid Services;
- Are furnished in connection with medical or other research; or
- Are considered by any governmental agency or subdivision to be experimental or
investigational, not considered reasonable and necessary, or any similar finding.
• When making decisions about whether treatments are investigational or experimental,
PacificSource relies on the above resources as well as:
- Expert opinions of specialists and other medical authorities;
- Published articles in peer-reviewed medical literature;
- External agencies whose role is the evaluation of new technologies and drugs; and
- External review by an independent review organization.
SingleSource Self-Insured 77
Exhibit'B'
• The following will be considered in making the determination whether the service is in an
experimental and/or investigational status:
- Whether there is sufficient evidence to permit conclusions concerning the effect of the
services on health outcomes;
- Whether the scientific evidence demonstrates that the services improve health outcomes as
much or more than established alternatives;
- Whether the scientific evidence demonstrates that the services' beneficial effects outweigh
any harmful effects; and
- Whether any improved health outcomes from the services are attainable outside an
investigational setting.
Formulary is a list of approved brand name medications used to treat various medical conditions. The
formulary list is developed by the pharmacy benefits management company and PacificSource.
Generic drugs are drugs that, under federal law, require a prescription by a licensed physician (M.D. or
D.O.) or other licensed medical provider and are not a brand name medication. By law, generic drugs
must have the same active ingredients as the brand name medication and are subject to the same
standards of their brand name counterpart.
Grievance means:
• A request submitted by a member or an authorized representative of a member;
- In writing, for an internal appeal or an external review; or
- In writing or orally, for an expedited internal review or an expedited external review; or
• A written complaint submitted by a member or an authorized representative of a member regarding:
- The availability, delivery, or quality of a healthcare service,
- Claims payment, handling, or reimbursement for healthcare services and, unless the member
has not submitted a request for an internal appeal, the complaint is not disputing an adverse
benefit determination; or
- Matters pertaining to the contractual relationship between a member and PacificSource.
Health care provider means a physician, practitioner, nurse, hospital or specialized treatment facility
as defined in this document.
Health benefit plan means any hospital expense, medical expense, or hospital or medical expense
policy or certificate, healthcare contractor or health maintenance organization subscriber contract, or
any plan provided by a multiple employer welfare arrangement or by another benefit arrangement
defined in the federal Employee Retirement Income Security Act of 1974, as amended, to the extent
that plan is subject to state regulation.
Hearing aids mean any nondisposable, wearable instrument or device designed to aid or compensate
for impaired human hearing and any necessary ear mold, part, attachments or accessory for the
instrument or device, except batteries and cords. Hearing aids include any amplifying device that does
not produce as its output an electrical signal that directly stimulates the auditory nerve. For the purpose
of this definition, such amplifying devices include air conduction and bone conduction devices, as well
as those that provide vibratory input to the middle ear.
Homebound means the ability to leave home only with great difficulty with absences infrequently and
of short duration. Infants and toddlers will not be considered homebound without medical
documentation that clearly establishes the need for home skilled care. Lack of transportation is not
considered sufficient medical criterion for establishing that a person is homebound.
Hospital means an institution licensed as a 'general hospital' or'intermediate general hospital' by the
appropriate state agency in the state in which it is located.
Illness includes a physical or mental condition that results in a covered expense. Physical illness is a
disease or bodily disorder. Mental illness is a psychological disorder that results in pain or distress and
substantial impairment of basic or normal functioning.
Incurred expense means charges of a healthcare provider for services or supplies for which a member
becomes obligated to pay. The expense of a service is incurred on the day the service is rendered, and
the expense of a supply is incurred on the day the supply is delivered.
SingleSource Self-Insured 78
Exhibit 'B'
Initial enrollment period means a period of 31 days following the date an individual is first eligible to
enroll.
Injury means bodily trauma or damage that is independent of disease or infirmity. The damage must be
caused solely by external and accidental means and does not include muscular strain sustained while
performing a physical activity.
Inquiry means a written request for information or clarification about any subject matter related to the
member's health benefit plan.
Internal appeal means a review by PacificSource or your Plan Sponsor of an adverse benefit
determination made by PacificSource.
Leave of absence is a period of time off work granted to an employee by the Plan Sponsor at the
employee's request and during which the employee is still considered to be employed and is carried on
the employment records of the Plan Sponsor. A leave can be granted for any reason acceptable to the
Plan Sponsor, including disability and pregnancy.
Lifetime means the period of time a member is enrolled in this plan or any other Plan Sponsored by the
Plan Sponsor.
Mastectomy is the surgical removal of all or part of a breast or a breast tumor suspected to be
malignant.
Medically necessary means those services and supplies that are required for diagnosis or treatment of
illness or injury and that are:
• Consistent with the symptoms or diagnosis and treatment of the condition;
• Consistent with generally accepted standards of good medical practice in the state of Oregon, or
expert consensus physician opinion published in peer-reviewed medical literature, or the results of
clinical outcome trials published in peer-reviewed medical literature;
• As likely to produce a significant positive outcome as, and no more likely to produce a negative
outcome than, any other service or supply, both as to the disease or injury involved and the
patient's overall health condition;
• Not for the convenience of the member or a provider of services or supplies;
• The least costly of the alternative services or supplies that can be safely provided. When
specifically applied to a hospital inpatient, it further means that the services or supplies cannot be
safely provided in other than a hospital inpatient setting without adversely affecting the patient's
condition or the quality of medical care rendered.
Services and supplies intended to diagnose or screen for a medical condition in the absence of signs or
symptoms, or of abnormalities on prior testing, including exposure to infectious or toxic materials or
family history of genetic disease, are not considered medically necessary under this definition (see
General Exclusions - Screening tests).
Medical supplies means items of a disposable nature that may be essential to effectively carry out the
care a physician has ordered for the treatment or diagnosis of an illness or injury. Examples of medical
supplies include but are not limited to syringes and needles, splints and slings, ostomy supplies, sterile
dressings, elastic stockings, enteral foods, drugs or biologicals that must be put directly into the
equipment in order to achieve the therapeutic benefit of the durable medical equipment or to assure the
proper functioning of this equipment (e.g. Albuterol for use in a nebulizer).
Member means an individual insured through the Plan Sponsor.
Mental and/or chemical healthcare facility means a corporate or governmental entity or other
provider of services for the care and treatment of chemical dependency and/or mental or nervous
conditions which is licensed or accredited by the Joint Commission on Accreditation of Hospitals or the
Commission on Accreditation of Rehabilitation Facilities for the level of care which the facility provides.
Mental and/or chemical healthcare program means a particular type or level of service that is
organizationally distinct within a mental and/or chemical healthcare facility.
Mental and/or chemical healthcare provider means a person that has met the credentialing
requirements of PacificSource, is otherwise eligible to receive reimbursement under the policy and is:
• A healthcare facility where appropriately licensed or accredited by the Commission on Accreditation
of Hospitals or the Commission on Accreditation of Rehabilitation Facilities;
• A residential program or facility;
SingleSource Self-Insured 79
Exhibit 'B'
• A day or partial hospitalization program,
• An outpatient service; or
• An individual behavioral health or medical professional authorized for reimbursement under Oregon
law.
Mental or nervous conditions means all disorders listed in the 'Diagnostic and Statistical Manual of
Mental Disorders, DSM-IV-TR, Fourth Edition' except for:
• Mental Retardation (diagnostic codes 317, 318.0, 318.1, 318.2, 319);
• Learning Disorders (diagnostic codes 315.00, 315.1, 315.2, 315.9);
• Paraphilias (diagnostic codes 302.4, 302.81, 302.89, 302.2, 302.83, 302.84, 302.82, 302.9); and
• Gender Identity Disorders in Adults (diagnostic codes 302.85, 302.6, 302.9 - this exception does
not extend to children and adolescents 18 years of age or younger); and
• 'V' codes (diagnostic codes V15.81 through V71.09 - this exception does not extend to children five
years of age or younger for diagnostic codes V61.20, V6121, and V62.82).
Network not available means a member does not have reasonable geographic access to a
PacificSource participating provider for a medical service or supply.
Non-participating provider is a provider of covered medical services or supplies that does not directly
or indirectly hold a provider contract or agreement with PacificSource.
Non-preferred drugs are covered brand name medications not on the Preferred Drug List.
Orthotic devices means rigid or semirigid devices supporting a weak or deformed leg, foot, arm, hand,
back or neck or restricting or eliminating motion in a diseased or injured leg, foot, arm, hand, back or
neck. Benefits for orthotic devices include orthopedic appliances or apparatus used to support, align,
prevent, or correct deformities or to improve the function of movable parts of the body. An orthotic
device differs from a prosthetic in that, rather than replacing a body part, it supports and/or rehabilitates
existing body parts. Orthotic devices are usually customized for an individual's use and are not
appropriate for anyone else. Examples of orthotic devices include but are not limited to Ankle Foot
Orthosis (AFO), Knee Ankle Foot Orthosis (KAFO), Lumbosacral Orthosis (LSO), and foot orthotics.
PacificSource refers to PacificSource Health Plans. PacificSource is the claims administrator of the
Plan Sponsor's medical, vision and pharmacy coverage. References to PacificSource as paying claims
or issuing benefits means that PacificSource processes a claim in accordance with the provisions of the
Plan Sponsor's plans.
Participating provider means a physician, healthcare professional, hospital, medical facility, or
supplier of medical supplies that directly or indirectly holds a provider contract or agreement with the
plan.
Periapical x-ray is an x-ray of the area encompassing or surrounding the tip of the root of a tooth.
Periodontal maintenance is a periodontal procedure for patients who have previously been treated for
periodontal disease. In addition to cleaning the visible surfaces of the teeth (as in prophylaxis) surfaces
below the gum-line are also cleaned. This is a more comprehensive service than a regular cleaning
(prophylaxis).
Periodontal scaling and root planing means the removal of plaque and calculus deposits from the
root surface under the gum line.
Physical/occupational therapy is comprised of the services provided by (or under the direction and
supervision of) a licensed physical or occupational therapist. Physical/occupational therapy includes
emphasis on examination, evaluation, and intervention to alleviate impairment and functional limitation
and to prevent further impairment or disability.
Physician means a state-licensed Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.).
Physician assistant is a person who is licensed by an appropriate state agency as a physician
assistant.
Plan means the City of Ashland Employee Benefits Plan, and all documents, including any insurance
contracts, administrative service agreements, Summary Plan Descriptions and any related terms and
conditions associated with the Plan.
SingleSource Self-Insured 80
Exhibit B'
Plan Administrator means the Risk Services Division of the City of Ashland, which has responsibility
for the management of the plan.
Plan Sponsor ('the Plan Sponsor' or'your Plan Sponsor'), means the City of Ashland. The City of
Ashland is the fiduciary of the plan, and exercises all discretionary authority and control over the
administration of the plan and the management and disposition of plan assets. The Plan Sponsor shall
have the sole discretionary authority to determine eligibility for plan benefits or to construe the terms of
the plan, and benefits under the plan will be paid only if the Plan Sponsor decides, in its discretion, that
the memberor beneficiary is entitled to such benefits. The Plan Sponsorhas the right to amend,
modify, or terminate the plan in any manner, at any time, regardless of the health status of any plan
member or beneficiary.
Plan Year means the twelve-month period of time for the City of Ashland beginning January 1, and
ending December 31.
Practitioner means Doctor or Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery
(D.D.S.), Doctor of Dental Medicine (D.M.D.), Doctor of Podiatry Medicine (D.P.M.), Doctor of
Chiropractic (D.C.), Doctor of Optometry (O.D.), Licensed Nurse Practitioner (including Certified Nurse
Midwife (C.N.M.) and Certified Registered Nurse Anesthetist (C.R.N.A.)), Registered Physical Therapist
(R.P.T.), Speech Therapist, Occupational Therapist, Psychologist (Ph.D.), Licensed Clinical Social
Worker (L.C.S.W.), Licensed Professional Counselor (L.P.C.), Licensed Marriage and Family Therapist
(LMFT), Licensed Psychologist Associate (LPA), Physician Assistant (PA), Audiologist, Acupuncturist,
Naturopathic Physician, and Licensed Massage Therapist.
Pre-existing condition means a condition (physical or mental) for which medical advice, diagnosis,
care, or treatment was recommended by or received from a licensed provider within the six-month
period ending on the enrollment date. For the purpose of this definition, the enrollment date of a
member is the earlier of the effective date of coverage or the first day of any required group eligibility
waiting period, and the enrollment date of a late enrollee is the effective date of coverage. Pregnancy
does not constitute a pre-existing condition, nor does genetic information without a diagnosis of a
condition related to such information.
Preferred is a list of approved brand name medications used to treat various medical conditions. The
Preferred Drug List is developed by the pharmacy benefits management company and PacificSource.
Prescription drugs are drugs that, under federal law, require a prescription by a licensed physician
(M.D. or D.O.) or other licensed medical provider.
Prophylaxis is a cleaning and polishing of all teeth.
Prosthetic devices (excluding dental) means artificial limb devices or appliances designed to replace
in whole or in part an arm or a leg. Benefits for prosthetic devices include coverage of devices that
replace all or part of an internal or external body organ, or replace all or part of the function of a
permanently inoperative or malfunctioning internal or external organ, and are furnished on a physician's
order. Examples of prosthetic devices include but are not limited to artificial limbs, cardiac pacemakers,
prosthetic lenses, breast prosthesis (including mastectomy bras), and maxillofacial devices.
Pulpotomy is the removal of a portion of the pulp, including the diseased aspect, with the intent of
maintaining the vitality of the remaining pulpal tissue by means of a therapeutic dressing.
Qualified domestic partner means a registered domestic partner or unregistered same gender
domestic partner with an Affidavit of Domestic Partnership, supplied by the Plan Sponsor.
Restoration is the treatment that repairs a broken or decayed tooth. Restorations include, but are not
limited to, fillings and crowns.
Routine costs of care means medically necessary conventional care, items, or services covered by
the health benefit plan if typically provided absent a clinical trial. Routine costs of care do not include:
• The drug, device, or service being tested in the clinical trial unless the drug, device, or service
would be covered for that indication by the policy if provided outside of a clinical trial;
• Items or services required solely for the provisions of the drug, device, or service being tested in
the clinical trial;
• Items or services required solely for the clinically appropriate monitoring of the drug, device, or
service being tested in the clinical trial;
• Items of services required solely for the prevention, diagnosis, or treatment of complications arising
from the provision of the drug, device, or service being tested in the clinical trial;
SingleSource Self-Insured 81
Exhibit B'
• Items or services that are provided solely to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient,
• Items or services customarily provided by a clinical trial sponsor free of charge to any participant in
the clinical trial; or
• Items or services that are not covered by the policy if provided outside of the clinical trial.
seasonal employee is an employee who is hired with the agreement that their employment will end
after a predetermined period of time.
Skilled nursing facility convalescent home means an institution that provides skilled nursing care
under the supervision of a physician, provides 24-hour nursing service by or under the supervision of a
registered nurse (R.N.), and maintains a daily record of each patient. Skilled nursing facilities must be
licensed by an appropriate state agency and approved for payment of Medicare benefits to be eligible
for reimbursement.
Specialized treatment facility means a facility that provides specialized short-term or long-term care.
The term specialized treatment facility includes ambulatory surgical centers, birthing centers, chemical
dependency/substance abuse day treatment facilities, hospice facilities, inpatient rehabilitation facilities,
mental and/or chemical healthcare facilities, organ transplant facilities, psychiatric day treatment
facilities, residential treatment facilities, skilled nursing facilities, substance abuse treatment facilities,
and urgent care treatment facilities.
Specialty drugs are high dollar oral, injectable, infused or inhaled biotech medications prescribed for
the treatment of chronic and/or genetic disorders with complex care issues that have to be managed.
The major conditions these drugs treat include but are not limited to: cancer, HIV/AIDS, hemophilia,
hepatitis C, multiple sclerosis, Crohn's disease, rheumatoid arthritis, and growth hormone deficiency.
Specialty pharmacies specialize in the distribution of specialty drugs and providing pharmacy care
management services designed to assist patients in effectively managing their condition.
Stabilize means to provide medical treatment as necessary to ensure that, within reasonable medical
probability, no material deterioration of an emergency medical condition is likely to occur during or to
result from the transfer of the patient from a facility; and with respect to a pregnant woman who is in
active labor, to perform the delivery, including the delivery of the placenta.
Subscriber means an employee or former employee insured under the Plan Sponsor's health policy
through PacificSource. When a family unit that does not include an employee or former employee is
insured under a policy, the oldest family member is referred to as the subscriber.
Surgical procedure means any of the following operative procedures:
• Procedures accomplished by cutting or incision
• Suturing of wounds
• Treatment of fractures, dislocations, and burns
• Manipulations under general anesthesia
• Visual examination of the hollow organs of the body including biopsy, or removal of tumors or
foreign body
• Procedures accomplished by the use of cannulas, needling, or endoscopic instruments
• Destruction of tissue by thermal, chemical, electrical, laser, or ultrasound
Telemedical means medical services delivered through a two-way video communication that allows a
provider to interact with a patient who is at a different physical location than the provider..
Temporomandibular Joint Disorder (TMJ) means any dysfunction or disorder of the jaw joint
resulting in pain and impairment of the jaw.
Third Party Administrator is an administrator hired by the Plan Sponsor to perform claims processing
and other specified administrative services in relation to the plan. The third party administratoris not an
insurer of health benefits under this plan, is not a fiduciary of the plan, and does not exercise any of the
discretionary authority and responsibility granted to the Plan Sponsor. The third party administrator is
not responsible for plan financing and does not guarantee the availability of benefits under this plan.
The third party administrator is PacificSource Health Plans
SingleSource Self-Insured 82
Exhibit'B'
Tobacco use cessation program means a program recommended by a physician that follows the
United States Public Health Services guidelines for tobacco use cessation. Tobacco use cessation
program includes education and medical treatment components designed to assist a person in ceasing
the use of tobacco products.
Unregistered domestic partner means an individual of the same-gender who is joined in a domestic
partnership with the subscriber and meets the following criteria:
• Is at least 18 years of age;
• Not related to the policyholder by blood closer than would bar marriage in Oregon or the state
where they have permanent residence and are domiciled;
• Shares jointly the same permanent residence with the policyholder for at least six months
immediately preceding the date of application to enroll and intent to continue to do so indefinitely,
• Has joint financial accounts with the policyholder and has agreed to be jointly responsible with the
policyholder for each others' common welfare, including basic living expenses;
• Has an exclusive domestic partnership with the policyholder and has no other domestic partner;
• Does not have a legally binding marriage nor has had another domestic partner within the previous
six months;
• Was mentally competent to consent to contract when the domestic partnership began and remains
mentally competent.
Urgent care treatment facility means a healthcare facility whose primary purpose is the provision of
immediate, short-term medical care for minor, but urgent, medical conditions.
Waiting period means the period of time before coverage becomes effective for a memberwho is
otherwise eligible to enroll in the plan.
Women's healthcare provider means an obstetrician, gynecologist, physician assistant or nurse
practitioner specializing in women's health, or certified nurse midwife practicing within the applicable
scope of practice.
RIGHTS OF PLAN MEMBERS
MEDICAID AND CHIP STATE CONTACT INFORMATION
If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from
your Plan Sponsor, your State may have a premium assistance program that can help pay for
coverage. These States use funds from their Medicaid or CHIP programs to help people who are
eligible for these programs, but also have access to health insurance through their Plan Sponsor. If you
or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium
assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below,
you can contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of
your dependents might be eligible for either of these programs, you can contact your State Medicaid or
CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you
qualify, you can ask the State if it has a program that might help you pay the premiums for a Plan
Sponsor-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid
or CHIP, as well as eligible under your Plan Sponsor plan, your Plan Sponsor must permit you to enroll
in your Plan Sponsor plan if you are not already enrolled. This is called a 'special enrollment'
opportunity, and you must request coverage within 60 days of being determined eligible for
premium assistance. If you have questions about enrolling in your Plan Sponsor plan, you can contact
the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA
(3272).
If you live in one of the following States, you may be eligible for assistance paying your Plan Sponsor
health plan premiums. The following list of States is current as of July 31, 2012. You should contact
your State for further information on eligibility -
SingleSource Self-Insured 83
Exhibit'B'
ALABAMA - Medicaid COLORADO - Medicaid
Website: http://www.medicaid.alabama.gov Medicaid Website: http://www.colorado.gov/
Phone: 1-855-692-5447 Medicaid Phone (In state): 1-800-866-3513
ALASKA - Medicaid Medicaid Phone (Out of state): 1-800-221-3943
Website:
http://health.hss.slate.ak.us/dpalprograms/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA - CHIP FLORIDA - Medicaid
Website: http://www.azahcccs.gov/applicants Website: https://www.flmedicaidtpirecovery.com/
Phone (Outside of Maricopa County): 1-877-764-5437 Phone: 1-877-357-3268
Phone (Maricopa County): 602-417-5437 GEORGIA - Medicaid
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150
IDAHO - Medicaid and CHIP MONTANA - Medicaid
Medicaid Website: Website:
www.accesstohealthinsurance.idaho.gov http://medicaidprovider.hhs.mt.gov/clientpages/
Medicaid Phone: 1-800-926-2588 clientindex.shtml
CHIP Website: www.medicaid.idaho.gov Phone: 1-800-694-3084
CHIP Phone: 1-800-926-2588
INDIANA - Medicaid NEBRASKA - Medicaid
Website: http://www.in.gov/fssa Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-889-9949 Phone: 1-800-383-4278
IOWA - Medicaid NEVADA - Medicaid
Website: www.dhs.state.ia.us/hipp/ Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562 Medicaid Phone: 1-800-992-0900
KANSAS - Medicaid
Website: http://www.kdheks.gov/hd/
Phone: 1-800-792-4884
KENTUCKY - Medicaid NEW HAMPSHIRE - Medicaid
Website: http://chfs.ky.gov/dms/default.htm Website:
Phone: 1-800-635-2570 http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA - Medicaid NEW JERSEY - Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov Medicaid Website:
Phone: 1-888-695-2447 http:/NdWw.state.nj.us/humanservices/
MAINE - Medicaid dmahs/clients/medicaid/
Website: http://www.maine.gov/dhhs/ofi/public- Medicaid Phone: 1-800-356-1561
assistance/index.html CHIP Website:
Phone: 1-800-977-6740 http:/hvwv.njfamilycare.org/index.html
TTY 1-800-977-6741 CHIP Phone: 1-800-701-0710
MASSACHUSETTS - Medicaid and CHIP NEW YORK - Medicaid
Website: http://www.mass.gov/MassHealth Website:
Phone: 1-800-462-1120 http:/twww.nyhealth.gov/health-care/medicaid/
Phone: 1-800-541-2831
MINNESOTA - Medicaid NORTH CAROLINA - Medicaid
Website: http://www.dhs.state.mn.us/ Website: http://www.ncdhhs.gov/dma
Click on Health Care, then Medical Assistance Phone: 919-855-4100
Phone: 1-800-657-3629
MISSOURI - Medicaid NORTH DAKOTA - Medicaid
Website: Website:
http:/Avww.dss.mo.gov/mhd/participants/pages/hipp.ht http://www.nd.gov/dhs/services/medicalserv/mediGai
m d/
Phone: 573-751-2005 Phone: 1-800-755-2604
OKLAHOMA - Medicaid and CHIP UTAH - Medicaid and CHIP
Website: http://www.insureoklahoma.org Website: http:/lhealth.utah.gov/upp
Phone: 1-888-365-3742 Phone: 1-866-435-7414
SingleSource Self-Insured 84
Exhibit'B'
OREGON - Medicaid and CHIP VERMONT- Medicaid
Website: http://www.oregonhealthykids.gov Website: http://www.greenmountaincare.org/
http://www.hijossaludablesoregon.gov Phone: 1-800-250-8427
Phone: 1-877-314-5678
PENNSYLVANIA - Medicaid VIRGINIA - Medicaid and CHIP
Website: http:/twww.dpw.state.pa.us/hipp Medicaid Website:
Phone: 1-800-692-7462 http://www.dmas.virginia.gov/rcp-HIPP.htm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
RHODE ISLAND - Medicaid WASHINGTON - Medicaid
Website: www.ohhs.ri.gov Website:
Phone: 401-462-5300 http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone: 1-800-562-3022 ext. 15473
SOUTH CAROLINA - Medicaid WEST VIRGINIA - Medicaid
Website: http://www.scdhhs.gov Website: www.dhhr.wv.gov/bms/
Phone: 1-888-549-0820 Phone: 1-877-598-5820, HMS Third Party Liabilit
SOUTH DAKOTA - Medicaid WISCONSIN - Medicaid
Website: http://dss.sd.gov Website: http://www.badgercareplus.org/pubs/p-
Phone: 1-888-828-0059 10095.htm
Phone: 1-800-362-3002
TEXAS - Medicaid WYOMING - Medicaid
Website: htips://www.gethipptexas.com/ Website:
Phone: 1-800-440-0493 http://health.wyo.gov/healthcarefiin/equalitycare
Phone: 307-777-7531
To see if any more States have added a premium assistance program since July 31, 2012, or for more
information on special enrollment rights, you can contact either:
U.S. Department of Labor U.S. Department of Health & Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cros.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565
OMB Control Number 1210-0137 (expires 09130/2013)
SingleSource Self-Insured 85
Exhibit'B'
SingleSource Self-Insured 86
Exhibit'B'
PLAN INFORMATION
Name and Address of the Plan Sponsor
City of Ashland
20 East Main
Ashland, OR 97520
(541) 488-6002
Name and Address of the Designated Agent for Service of Legal Process
Dave Kanner, City Administrator
20 East Main
Ashland, OR 97520
541-488-6002
Name and Address of the Third Party Administrator
PacificSource Health Plans
PO Box 7068
Springfield, OR 97475-0068
(888) 977-9299
Fax: (541) 684-5264
Internal Revenue Service and Plan Identification Number
The corporate tax identification number assigned by the Internal Revenue Service is
936002117.
Plan Year
The plan year is the 12-month period of time beginning January 1 and ending December 31.
Method of Funding Benefits
Health benefits are self-insured from the general assets and or trust funds of the Plan Sponsor
and are not guaranteed under an insurance policy or contract. The Plan Sponsor may purchase
excess risk insurance coverage which is intended to reimburse the Plan Sponsor for certain
losses incurred and paid under the plan by the Plan Sponsor. Such excess risk coverage, if
any, is not part of the plan. The cost of the plan is paid with contributions by the Plan Sponsor
and participating employees. The Plan Sponsor determines the amount of contributions to the
plan, based on estimates of claims and administration costs.
Payments out of the plan to health care providers on behalf of the covered person will be based
on the provisions of the plan.
SingleSource Self-Insured 87
Exhibit'B'
SingleSource Self-Insured 88
Exhibit'B'
SIGNATURE PAGE
The effective date of the Preferred 90+200 VAR GF 0812 is July 1, 2013.
It is agreed by the City of Ashland that the provisions of this document are correct and will be the
basis for the administration of the Preferred 90+200 VAR GF 0812.
Dated this day of
By
Title
SingleSource Self-Insured 89
Exhibit'B'
SingleSource Self-Insured 90
Exhibit'C'
DUTIES AND RESPONSIBILITIES OF THE EMPLOYEE HEALTH
BENEFITS ADVISORY COMMITTEE
In the interest of providing a quality health insurance benefit program on a consistent basis to
all regular City employees, the City Council will create an Employee Health Benefits Advisory
Committee (EHBAC). The primary responsibility of the EHBAC will be to meet with
Personnel staff, the agent of record, and insurance representatives, in order to review/evaluate
all possible options with regard to employee benefits. The EHBAC will make
recommendations to the City Council regarding insurance benefits.
Specific responsibilities of the EHBAC include:
• Review monthly loss run and claims reports to identify trends and issues that could pose
a threat to the fiscal integrity of the health insurance plan;
• Monitor the performance of the third party administrator and other benefit
administrators;
• Review and recommend deletions or additions to the health benefits plan, as well as
changes in deductibles, co-pays, out-of-pocket maximums and other direct employee
costs;
• Annually recommend to the City Council a plan document that establishes benefit levels
within budgetary constraints;
• Provide a forum for employees to raise concerns about specific elements of the health
benefits plan;
• Serve as a conduit for information and questions from employees to the committee and
the plan administrator.
Members of the EHBAC shall at all times protect confidential information from disclosure and
shall honor requests for confidentiality from individual employees who have concerns or who
want to offer suggestions and input to the committee anonymously. EHBAC members are not
expected to resolve problems and concerns with individual claims or to contact the third party
administrator or other benefits administrators. Such contacts should be made only by the
Human Resources Office or the plan administrator.
EHBAC MEMBERSHIP
The EHBAC will be comprised of the following voting membership:
One representative from IBEW Local 659 (ClericaVTechnical)
One representative from IBEW Local 659 (Electrical Workers)
One representative from the Ashland Firefighter's Association
One representative from the Ashland Police Association
One representative from Laborers Union Local 121
One representative from the Parks and Recreation Department
Four management and/or non-represented employees
The City Administrator or designee will be a non-voting member of the committee. Additional
non-voting members may be appointed at the discretion of the committee. Committee
Exhibit'C'
membership may be modified from time to time in order to ensure an equal balance of
represented and non-represented employees.
A Chair and Vice Chair will be selected annually by the committee, with one position to be
filled by a manager and the other will be a non-management representative.
The Human Resources Office will provide staff support to the committee.
MINIMUM MEETING REQUIREMENTS
At a minimum, the EHBAC will strive to meet monthly and in no case less than eight (8) times
per year. Additional meetings may be scheduled at the discretion of the committee.
Subcommittees may also be established at the discretion of the committee.
The EHBAC may request the removal or replacement of a voting member who is not able to
attend two (2) or more consecutive EHBAC meetings, or four (4) or more meetings in any
twelve-month period.
No vote shall be taken on any recommendation to the City Council in an EHBAC meeting
without a quorum present. A quorum is defined as a majority of the voting members, not
including vacant positions.
The meetings will be open to all interested employees. Minutes of each meeting will be kept
and in turn distributed to each committee member, the City Council and Department Heads, and
will be posted on department bulletin boards. All employees with an e-mail address will
receive notice of planned meetings and an electronic copy of the minutes of each meeting.