ORD 34044 - Contract with Blue Cross Blue Shield for administrative services for self-insured health program• w
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of 84'1 Finance Department
Omaha/Douglas Civic Center
6047,45
t 1819 Farnam Street,Suite 1004
V1 ! nT ro Omaha,Nebraska 68183-1004
(402)444-5416
Telefax(402)444-5423
�4?ED FEBRU�
Louis A.D'Ercole
City of Omaha Acting Director
Hal Daub,Mayor
October 29, 1996
Honorable President
and Members of the City Council,
The attached Ordinance authorizes the City of Omaha to enter into a three year agreement with Blue
Cross/Blue Shield of Nebraska to process the City's health insurance claims,provide pre-certification
services,provide a Preferred Provider Organization(PPO)and provide insurance for specified organ
transplant surgeries. The City retained Insurance Consultants, Inc. to assist in both developing the
health insurance bid specifications and evaluating the responses and recommending the lowest and
best bid for the City. The City received two proposals from Blue Cross/Blue Shield of Nebraska and
Mutual of Omaha which were deemed to be consistent with the specifications.
The contractor has on file a current Annual Contract Compliance Report Form(CC-1). As is City
policy, the Human Relations Director will review the contractor to ensure compliance with the
Contract Compliance Ordinance.
Insurance Consultants Inc. evaluated the proposals and recommended that the City award the
contract to Blue Cross/Blue Shield. The major reasons for this recommendation may briefly be
summarized as:
• The lower administration charge.
• The broader managed care network
• The ability to guarantee claim dollar savings
• Experience in providing services to the City of Omaha
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Honorable President
and Members of the City Council
Page 2
The City Departments of Finance, Law and Personnel have reviewed the bid specifications,
proposals, and the consultants' recommendation and concur with the Blue Cross/Blue Shield
recommendation. Attached are reports by Insurance Consultants, Inc. which provide more detail
concerning its recommendations.
Respectfully submitted, Approved:
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Louis A. D'Ercole Mi . Frost
Acting Finance Director Personnel Director
Approved: Approved:
Herbe M. Fitle Georg�avis, Jr.
City Attorney Acting Human Relations Director
Referred to city Council for Consideration:
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Mayor's Office/Title na...)
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ORDINANCE NO. 1/Q y� •
AN ORDINANCE to approve and execute a contract involving the payment of money from
appropriations of more than one year in accordance with section 5.17 of the Home Rule
Charter of the City of Omaha, 1956, as amended, by and between the City of Omaha, a
municipal corporation, and Blue Cross Blue Shield of Nebraska, to provide the
administrative services for the City's self-insured health program for a period of thirty-six
months, commencing on January 1, 1997, and ending December 31, 1999, in accordance
with the lowest and best proposal submitted by said Blue Cross Blue Shield of Nebraska; and
to provide the effective date hereof.
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF OMAHA:
Section 1. That authority is hereby given for the execution of a Contract involving the
payment of money from appropriations of more than one year in accordance with Section 5.17 of
the Home Rule Charter of the City of Omaha, 1956,as amended,by and between the City of Omaha,
a municipal corporation,and Blue Cross Blue Shield of Nebraska,for administrative services for the
City's self-insured health program including participation in a Preferred Provider Organization plan
and continuation of a Prescription Card Program for the period from January 1, 1997, to December
31, 1999, in accordance with the proposal of the said Blue Cross Blue Shield of Nebraska.
Section 2. That the Mayor of the City of Omaha be, and he hereby is, authorized and
empowered to execute for and on behalf of the City of Omaha,and the City Clerk to attest,a contract
authorized and approved in Section 1 hereof, attached hereto and marked Exhibit "A" and by this
reference made a part hereof as fully as if set forth herein.
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ORDINANCE NO. 39,9 W
PAGE 2
Section 3. That this ordinance shall be in full force and take fifteen days from and after the
date of its passage.
INTRODUCED BY COUNCILMEMBER:
• APPROVED BY:
•YOR OF THE CITY OF OMAHA DA 1 E
PASSED NOV 1 9 1996
ATTEST:
CIT CLERK O THE CITY OF OMAHA APPROVED AS TO FORM:
E UTY CIT TTORNEY
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EXHIBIT "A"
ADMINISTRATIVE SERVICES AGREEMENT
THIS AGREEMENT is entered into by and between the City of Omaha, a Municipal
Corporation in Douglas County,Nebraska, also referred to as "Plan Administrator," and Blue Cross
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and Blue Shield of Nebraska, 7261 Mercy Road, Omaha,Nebraska(the "Company").
RECITALS:
WHEREAS,the Plan Administrator is serving as such pursuant to designated health benefit
plans known as City of Omaha Group Health Program Schedule of Benefits (the "Plan"), copies of
which are attached hereto and marked as Exhibits "B-1" and"B-2",for certain employees("Covered
Employees") and/or their dependents, as defined in Exhibits "B-1" and "B-2" as follows:
B-1 Base/Major Medical as of December 31, 1993
• Police uniform with pre-certification/and Prescription Card Program
• Civilian Bargaining retirees prior to January 1, 1991
• Civilian Management including AEC retirees prior to January 1, 1991
• Police Uniform retirees prior to June 1, 1992
• Police Uniform retirees after June 1, 1992 with pre-certification
• Police Uniform retirees after July 1, 1995 with pre-certification/Prescription Card
Program
• Fire Uniform retirees before March 1, 1991
• Fire Uniform retirees between March 1, 1991 and December 31, 1991 with
pre-certification
• Police or Fire Management retires before June 1, 1992
B-2 Comprehensive Major Medical with Preferred Provider Organization (PPO) with
pre-certification and Prescription Card Program.
• Fire Uniform (excluding Prescription Card Program)
• Civilian Bargaining
• Civilian Management, including AEC
• Functional
• Civilian Bargaining Retirees after January 1, 1991 with precertification
• Civilian Bargaining Retirees after January 1, 1994 with precertification and
Prescription Card Program
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• Civilian Management, including AEC retirees after January 1, 1991 with
precertification
• Civilian Management, including AEC retirees after October 1, 1994 with
precertification and Prescription Card Program
• Fire Uniform retirees after January 1, 1992
• Functional retirees
• Police or Fire Management (exclude Prescription Card Program - Fire)
• Police or Fire Management retirees after June 1, 1992
• Police Management retirees after January 1, 1996 with precertification and
Prescription Card Program
Covered Employees and their dependents shall be referred to in this agreement where
appropriate as "Covered Persons"; and,
WHEREAS, the City of Omaha continues to extend to covered persons the option of
receiving health insurance benefits under a Prescription Card Program which will be administered
and maintained by the Company; and,
WHEREAS the Company has expertise in various aspects of health plan administration;and,
WHEREAS, the Plan Administrator desires to engage the Company to provide certain
administrative services for the Plan, and the Company is willing to provide such services; and,
WHEREAS,the Plan Administrator desires to engage the company to provide insurance on
a shared basis for coverage for specific whole organ transplants, and the Company is willing to
provide such services. (Exhibit "C" and "D-1")
NOW, THEREFORE, in consideration of the mutual promises and duties set forth in this
agreement, the parties hereto, intending to be legally bound, do agree as follows:
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ARTICLE I
ADMINISTRATIVE SERVICES
1.1 The Company shall, at its expense,maintain adequate and necessary records on each
Covered Employee for the proper administration of the Plan. The records maintained on each
Covered Employee shall include, but are not limited to:
(a) Full name;
(b) Marital status;
(c) Date of birth;
(d) Effective date of coverage;
(e) Election of dependent coverage and names of dependents; and,
(f) Records pertinent to maintenance of coordination of benefits.
These records shall be available for inspection by the Plan Administrator during regular business
hours.
1.2 The Company shall prepare and issue,through the Plan Administrator,identification
cards and if necessary prescriptions cards, and a Plan summary for all Covered Employees. The
identification cards including prescription cards shall be evidence of participation in the Plan and
shall be presented by the Covered Person to the provider of medical services, supplies or equipment.
These cards shall identify the Covered Employee, the Plan, and the Company.
1.3 The Company will provide the Plan Administrator with all of the forms necessary for
the enrollment and maintenance of a Covered Person's records and for the Covered Person's
submission of claims for benefits.
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1.4 The Company shall, as a part of this agreement, provide a conversion coverage
privilege for qualified Covered Employees who terminate employment with the City. Such
conversion coverage shall be the same conversion coverage made available for persons who leave
groups which are underwritten by the Company.
1.5 The Company will provide the Plan Document and any necessary amendments,
revisions, or modifications thereto. The Company will not change any provisions in the Plan
Document without prior written approval of the City's authorized representative. The Company will
continually advise the Plan Administrator, and in no event on less than a calendar quarterly basis,
beginning on April 30, 1997, of cost estimates and projections of the Plan to its best ability in
conjunction with its preparation of accounting reports for use by the Plan Administrator.
1.6 The services of the entire organization and personnel of the Company are available
for the performance of its duties and responsibilities pursuant to this agreement.
ARTICLE II
CLAIM SERVICE
2.1 The Company shall review claims which are submitted for services provided to
Covered Persons to determine whether benefits are payable under the terms of the Plan. The
Company shall conduct such examination as is reasonable to determine whether benefits are payable
under the Plan. The Company shall pay or reject no less than 80 percent of the claims received
within 7 calendar days and 90 percent of the claims received within 14 calendar days from the date
of the receipt of the claim excluding all claims which must be provided for externally obtained
information.
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2.2 The Company shall make benefit payment from its own funds. Monthly paid claims
analysis reports shall be submitted to the Plan Administrator by the Company in the month
immediately following payment. The Plan Administrator shall reimburse the Company the amount
of these claims by the 15th day of that month if the claims analysis is submitted on or before the 12th
day thereof, or if not submitted by the 12th day thereof, then within three working days after
submission. It is expressly understood by and between the Company and the Plan Administrator that
reimbursement pursuant to this paragraph shall be only in that amount of the claim actually paid by
the Company, and in the event discounted rates are paid by the Company as a result of payment
pursuant to diagnostic related group agreements (hereinafter DRG),physician service discounts or
other provider discounts,then such discounted rates so paid shall be the limit of the City's liability
for reimbursement.
2.3 In the event that a claim is not payable,the Company will notify the Covered Person
and the Plan Administrator of such decision, including the reason for the denial,which shall include
the reference to the applicable provision of the Plan. The Covered Person has the right to appeal
such denial, and the Company will reconsider the denial of benefits and advise the Plan
Administrator and the Covered Person of its final determination. If the Covered Person requests
review of the denial by the Plan Administrator,the Company shall, if requested, make available a
qualified and informed agent who shall appear or provide necessary information for said review.
2.4 The Plan Administrator shall have the final authority to authorize or disallow benefit
payments.
2.5 The Company shall maintain current, accurate, and complete records and files which
allow the Plan Administrator to examine and analyze all claim submissions, health care provider
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agreements including but not limited to DRG agreements and payments made pursuant to same,
including payments on each Covered Person for a period of at least five years after the filing of the
claim. The Plan Administrator's authorized representatives shall have the reasonable right of access
to, and copies of,the records provided for herein during normal business hours for the purposes of
determining compliance with the agreement and performing any necessary audits. For the purpose
of conducting audits or requesting information,the Company shall maintain records available to the
Plan Administrator which include the amount of the bills received from medical providers, the
amount same have been reduced as a result of DRG agreements,physician service discounts or other
provider discounts, and the amount of payment made by the Company as a result of any discounted
rates resultant from any negotiated agreements. This provision is subject to the understanding of
both parties that certain records are of confidential nature, and the release of such information is
subject to the provisions of paragraph 2.6.
2.6 The Company will provide the Plan Administrator a monthly claims report of all
claims processed during that month. Such report will list:
(a) The claimant's name and the agreement number under which the claim has been
submitted;
(b) Whether the claimant is an employee or a dependent;
(c) The claimant's age and sex;
(d) The claimant's admission of performance date, and date of discharge;
(e) The type of care provided;
(f) The amount charged for such care;
(g) The amount paid for such care and the amount that same has been reduced by reason
of negotiated provider contract between hospitals and medical service providers,and
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the Company further warrants and guarantees that the amount of savings over the
term of this agreement from January 1, 1997, through and including December 31,
1999, resultant from said negotiated provider agreements shall be no less than
$5,000,000. In the event the actual savings is less than$5,000,000 the company will
issue a credit for the difference between the actual savings amount and the
guaranteed savings amount. If the actual savings is greater than $5,000,000 the
company will have fulfilled the savings guarantee;
(h) The difference, if any, between the amount charged and the amount paid because of
any negotiated provider contracts;
(i) The amount of any benefits credits.
(j) The amount of any subrogation claim as defined by Article IX (B-1) of Part XVI
(B-2),of the Master Group Contracts and the amount recovered by the Company in
satisfaction of that subrogation claim. It is understood that any subrogation claim for
which recovery has been successful shall be credited to the City, and that said
recovery shall constitute a savings to the City of Omaha. In the event the Company
does not pursue a subrogation claim which it is aware of, the Company shall advise
the City of the amount of said claim and the reason that recovery is not being
pursued. Additionally it is understood and agreed that any money recovered as a
subrogation claim shall not be considered part of or included in the savings computed
and guaranteed pursuant to the terms of paragraph 2.6(g).
This report will be mailed or delivered to the Plan Administrator within a reasonable time following
the close of the period covered by the report.
No employee-specific information regarding diagnosis and medical history will be released
without a written request from the Plan Administrator for such information. All Claim reviews by
the Plan Administrator will be conducted in such manner as to maintain the information provided
concerning the Covered Person confidentially. Plan Administrator agrees that health care provider
agreements are proprietary to the Company and that the Plan Administrator agrees that the contents
will not be released or provided to any individuals, companies or firms absent judicial process.
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The Plan Administrator further agrees to indemnify and hold harmless the Company from
any and all claims, demands, actions, or causes of action arising as a result of the release of
information by the Company to the Plan Administrator.
2.7 The Company shall provide the following at the frequency designated:
1. Hospital Utilization by Diagnostic Category -- Semiannually.
2. Utilization Report by Procedure Code -- Quarterly.
3. Utilization Report not Defined by Procedure Codes -- Quarterly.
4. In-patient Experience by Hospital -- Quarterly.
5. Cost Savings Report-- Monthly.
6. Members with Claims Totaling $10,000 or More -- Monthly.
7. Group Experience Report-- Monthly.
8. Total Experience by Age and Sex--Annually.
9. A Turn Around Report which would show the Claim Turn Around Time --Monthly.
10. A Customer Service Inquiry Report which would show the Types of Inquiries being
asked by Employees -- Monthly.
11. A Claim Lag Report-- Semiannually.
12. Utilization of Prescription Card Report- Quarterly.
2.8 The Claims services listed in this Article II are not intended to limit the claim services
provided by the Company and may be expanded as is advisable for the proper administration of the
Plan.
2.9 The Company will provide to the Plan Administrator notice of irregularities in claims
submissions which result in, or would result in, overpayment of benefits, and which have been
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confirmed by the Company's investigation. Such irregularities shall include but not be limited to
claims submitted with altered charges or service information and claims for services which were not
provided.
ARTICLE III
ADDITIONAL SERVICES
3.1 The Company, within the scope of its professional ability, shall provide consulting
services to the Plan Administrator for plan design, actuarial analysis, and administration of the Plan
as may be required or advisable.
3.2 In accordance with the Plan Administrator's instructions,the Company shall solicit,
collect and compile information or data pertaining to potential plan changes. This section may be
considered and utilized as additional services when the performance of the Company hereunder is
not within the scope of the duties and responsibilities of the Company as set forth more specifically
in any other provisions, and the Company may make such additional services the subject of a claim
for reimbursement for the expenses so incurred, if prior to incurring those expenses, the Company
has advised the City that such services will be an additional expense.
3.3 The Company shall incorporate and/or administer any change to the health insurance
plan,when notified directly by the Plan Administrator, for various classes of employees and shall,
to every extent reasonable and practicable, administer those changes in the health insurance benefits
incorporated into the current labor agreements or understanding between the City of Omaha and its
participating employees. It is expressly understood that the Company has no authority to unilaterally
or independently make any change in the benefits or methods of processing same without the express
prior written approval of the Plan Administrator.
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3.4 The Company shall provide personnel to assist in orientation and training concerning
the benefits provided under this Plan.
ARTICLE IV
ADMINISTRATOR'S RESPONSIBILITIES
4.1 The Plan Administrator shall provide the Company with the necessary enrollment
records of the Covered Employees as of the effective date of this agreement. Thereafter, the Plan
Administrator shall notify the Company of all changes by reason of termination,changes,or addition
of new Covered Employees. The Company shall not be liable for any action it has taken on behalf
of a Covered Person prior to its receipt of information that would have caused a different decision.
4.2 The Plan Administrator shall provide the Company with a true and accurate
accounting of all Covered Persons. The Company shall not be liable for any loss incurred as a result
of any inaccurate accounting of Covered Persons on the part of the Plan Administrator.
4.3 The Plan Administrator shall maintain a supply of forms, which are available from
the Company,and shall distribute or make available such forms to Covered Employees for the filing
of claims for benefits or to report changes in participation, when the form is not available by the
provider.
4.4 Except as provided in Section 1.5., the Plan Administrator shall provide to the
Company all materials, documents, and information as may be necessary for the operation of the
Plan, or to satisfy the requirements of governing law.
4.5 The Plan Administrator shall be responsible for satisfying any and all reporting and
disclosure requirements imposed on the Plan under applicable law. The Company will assist with
such requirements and provide the documents and materials necessary upon request.
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4.6 The Plan Administrator shall be responsible for any delay in the performance of the
administrative and claims service caused by the failure of the Plan Administrator to promptly furnish
notice of enrollment and/or termination of employees to the Company.
ARTICLE V
Preferred Provider Organizations (hereinafter P.P.O.) and Optional Prescription Card
Program.
The company shall administer a P.P.O.Program and a Prescription Card Program for covered
persons pursuant to the following conditions and understandings:
5.1 At mutually agreed times covered employees may,at their option,elect to participate
in a Prescription Card Program. The Company shall provide such forms as are necessary to
document the employee's election to have coverage provided under the terms and conditions of the
City's Prescription Card Program. That Program shall include the following:
(1) Each covered employee will be issued a "prescription card" which will allow the
covered employee or covered family member(s)to purchase prescriptions by paying,
at the time and site of purchase, 20% of the cost of each prescription after the
applicable yearly deductible has been satisfied.
(2) The yearly deductible shall be $60.00 for single or family. The prescription
deductible and co-payment are separate and distinct from the health insurance
deductible and co-payment, except prescriptions dispensed in the hospital, shall be
applied to the health insurance deductible and co-payment.
(3) The prescription card will be valid at the majority of pharmacies in the Omaha area;
however, it is understood that some small pharmacies may not participate. In order
to be covered for in-City charges, employee must use participating pharmacy.
(4) After a covered employee has expended$500 after payment of deductible (i.e., 20%
of$2,500 post-deductible prescription expenses) in a given calendar year, the card
will allow covered employees to obtain prescriptions at a flat rate of $3.00 per
prescription.
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(5) Covered persons who require medications(s) for a period of time in excess of thirty
days may be required to purchase such medications from a designated dispensary
through the U.S. mail.
5.2 The Company shall provide a list of all pharmacies participating in the Prescription
Card Program.
5.3 The Company shall provide to the covered employees a list of all hospitals and
physicians located or practicing within the appropriate service area who are participants in the
company's P.P.O. Program.
5.4 There shall be no waiting or probationary period for any covered person to qualify
under the P.P.O. program and the Prescription Card program, if at the time this contract is approved
and signed by the City, the health insurance program in effect at that time would consider the
employee or family to be covered persons under that current health insurance plan.
5.5 The Company shall be responsible for monitoring and assuring the quality of care
provided by P.P.O. providers. This shall include the following:
(a) Education and Credentials;
(b) Office Facility;
(c) Adequacy of Medical Records;
(d) Generic Process Screens;
(e) Diagnostic Specific Provisions of Care;
(f) Outcome review;
(g) Patient Satisfaction Surveys;
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5.6 The P.P.O.Plan Document and Prescription Card program shall generally be followed
unless there are conflicts with any labor agreements, or ordinances which may be contrary to its
provisions. A copy of said PPO plan document is attached hereto marked Exhibit "B-2" and
incorporated herein by reference.
ARTICLE VI.
FEES
6.1 For either the Administrative Services portion of the agreement; the in-hospital
Pre-certification or the Whole Organ Transplant Coverage. The Plan Administrator agrees to pay
the Company the fees set forth in Exhibit "C".
6.2 Nothing in this Article VI or Exhibit"C" shall prohibit the Company from performing
any service not enumerated in this agreement for a reasonable fee. Any such service and
corresponding fee may be provided only if agreed to by the Plan Administrator and the Company
in advance of such performance.
6.3 If the Plan Administrator, for any reason within its control, fails to make a required
payment on a timely basis,the Company may suspend the performance of its services until such time
as the Plan Administrator makes the proper remittance. The Company shall provide the Plan
Administrator within 15 calendar days, notice of its intent to take such action.
6.4 The Plan Administrator agrees to pay the Company the percentage of claims set forth
in Exhibit "C" for paying claims run out after January 1,2000, should the City of Omaha change the
company providing administrative service. The claims run out will be only for those claims incurred
prior to January 1, 2000, but not yet processed as of December 31, 1999. Such claim run out will
be allowed only through March 31, 2000.
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ARTICLE VII
MISCELLANEOUS PROVISIONS
7.1 In no instance shall the Company be deemed the Administrator of the Plan,as defined
in Section 3(16) of the Employee Retirement Income Security Act of 1974, as amended, or for
purposes of any other applicable state or local law affecting or regulating the Plan.
7.2 The Company shall not be considered the insurer or underwriter of the liability of the
Plan Administrator to provide benefits for Covered Persons. The Plan Administrator shall have the
final responsibility and liability for payment of claims under the Plan. The Plan Administrator shall
be responsible for all expenses incident to the operation of the Plan.
ARTICLE VIII
AMENDMENTS
8.1 This agreement may be amended by the Plan Administrator or the Company at any
time by mutual written consent of each party; provided, however, this agreement may not be
amended to reduce any benefits which might be paid for any cause incurred prior to the amendment,
or to in any way prejudice such a claim.
ARTICLE VIX
DURATION OF THIS AGREEMENT
9.1 This agreement shall take effect as of 12:01 a.m., January 1, 1997, and expire
December 31, 1999; at 12:00 midnight. This agreement shall automatically be renewed for a period
of 60 days until terminated in writing by either party.
9.2 This agreement shall be construed and enforced according to the laws of the State of
Nebraska.
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ARTICLE X
TERMINATION OF THIS AGREEMENT
10.1 This agreement may be terminated by either party by written notice to the other party,
to be effective as of the date set forth in said notice; provided that such date shall not be less than
thirty (30) days from the date of receipt of such notice unless mutually agreeable to both parties.
10.2 This agreement shall automatically terminate in the event of:
(a) The Plan Administrator's failure to pay the fees provided in Exhibit "C" within thirty
(30) days of their due date;
(b) The Plan Administrator's failure to reimburse the Company for benefit payment as
required by paragraph 2.2.
(c) Adjudicated bankruptcy or insolvency of Blue Cross and Blue Shield of Nebraska;
(d) Failure of the Plan Administrator to promptly deliver any data specified herein which
is necessary for the proper performance of duties;
(e) The enactment of any law or regulation which makes illegal the continuance of this
agreement.
10.3 In the event of termination of this agreement, the Company shall complete the
processing of all requests for claim payments under the Plan which were received by it and are due
and payable prior to the termination of this agreement. The Company shall have no obligation to
pay or process claims relative to services provided for conditions existing on or after the termination
of this agreement.
10.4 The Company shall return to the Plan Administrator all claims which were incurred
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and received by them after the date of termination established herein.
10.5 The Company shall,within 60 days of the last transaction required under this Article
IX, deliver to the Plan Administrator a complete and final accounting and report of the financial
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status of the Plan,together with copies of all books and records in its possession with respect to the
Plan, all claims files, and all reports and other papers pertaining to the Plan. The Company retains
the right to keep originals of all documents.
ARTICLE XI
EQUAL EMPLOYMENT OPPORTUNITY CLAUSE
11.1 Annexed hereto as Exhibit "D" and made a part hereof by reference are the equal
employment provisions of this agreement. Refusal by the Company to comply with any portion of
this program, as therein stated and described, will subject the offending party to any or all of the
following penalties:
(a) Withholding of all future payments under the involved contracts to the Company in
violation until it is determined that the Company is in compliance with the provisions
of the contract;
(b) Refusal of all future bids for any contracts with the Plan Administrator or any of its
departments or divisions until such time as the Company demonstrates that it has
established and shall carry out the policies of the program as herein outlined.
ARTICLE XII
NONDISCRIMINATION
12.1 The Company shall not, in the performance of this agreement,discriminate or permit
discrimination in violation of federal or state laws or local ordinances, because of race, color, sex,
age, political or religious opinions, affiliations or national origin.
ARTICLE XIII
INTEREST OF THE PLAN ADMINISTRATOR
13.1 Pursuant to Section 8.05 of the Home Rule Charter,no elected official or any officer
or employee of the City shall have a financial interest, direct or indirect, in any City contract. Any
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violation of this section,with the knowledge of the person or corporation contracting with the City,
shall render the contract voidable by the Mayor or Council.
ARTICLE XIV
INTEREST OF BLUE CROSS AND BLUE SHIELD OF NEBRASKA
14.1 The Company covenants that it presently has no interest and shall not acquire any
interest, direct or indirect, which would conflict with the performance of services required to be
performed under this agreement; it further covenants that in the performance of this agreement, no
person having any such interest shall be employed.
ARTICLE XV
- MODIFICATION
15.1 This agreement contains the entire agreement of the parties. No representations were
made or relied upon by either party other than those that are expressly set forth herein. No agent,
employee or other representative of either party is empowered to alter any of the terms hereof unless
done in writing or signed by an authorized officer of the respective parties.
15.2 In the event the Plan administrator determines that benefits as recited in Exhibit "B"
are to be modified,then it shall notify the Company at least 30 days prior to the implementation of
said modification in benefits. It shall be the responsibility of the Company to continue to administer
the modified benefits consistent with the fee schedules recited in Exhibit "C".
ARTICLE XVI
ADDITIONAL FEES OR OTHER TAXES
16.1 If,during the term of this agreement,any tax(other than local, state or federal income
taxes) or any other assessment or premium charge, shall be assessed against the Company with
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respect to this agreement,the Company shall report the payment to the Plan Administrator, and the
Plan Administrator shall reimburse the Company for the same.
ARTICLE XVII
AUTHORIZED REPRESENTATIVE
In further consideration of the mutual covenants herein contained,the parties hereto expressly
agree that for purposes of notice, including legal service of process, during the term of this contract
and for the period of any applicable statute of limitations thereafter,the following named individuals
shall be the authorized representatives of the parties:
(1) City of Omaha
Louis A. D'Ercole, Acting-Finance Director
Omaha/Douglas Civic Center
1819 Farnam Street
Omaha,NE 68183
(2) Blue Cross and Blue Shield of Nebraska
Jerry Dworak, Vice President
7261 Mercy Road
Omaha,NE 68180
EXECUTED THIS day of(Oa—, 1996.
BLUE CROSS AND BLUE SHIELD
ATTEST: OF NEBRASKA
44/09.Lfr..ot/ / J By
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EXECUTED THIS2A lay of.. , 1996.
CITY OF OMAHA, a Municipal
ATTEST:_ Corporation
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By Or / ,6661,.,_
`, t Clerk, City of Omaha Ma •r, City of Omaha
APPROVED AS TO FORM:
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Deputy City orney
4836v
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EXHIBIT "B-1"
GROUP MASTER CONTRACT
between
BLUE CROSS AND BLUE SHIELD OF NEBRASKA
A Nebraska Non-Profit Corporation,with its Home Office at
7261 Mercy Road,Omaha, Nebraska 68124
Herein called the Company
and
•
the Applicant named in the Application herefor,
Herein called the Applicant
•
Effective beginning at 12:01 A.M. at the Applicant's principal place of business on the date stated in the Application.
In consideration of the Application for this Contract, a copy of which Application is attached hereto and made a part of
this Contract, and in accordance with the payment by the Applicant of the charges as herein provided,THE COMPANY
HEREBY AGREES TO PROVIDE PAYMENT for the services described, defined and limited herein, effective as stated
and from year to year thereafter,unless this Contract is terminated as provided herein.
This Contract is executed and delivered in the State of Nebraska,and is governed by the laws thereof.
Group— UCR 9711 1-80
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TABLE OF CONTENTS
PAGE
Article I. Definitions
2
Article II. Exclusions and Limitations 5
Article III. Standard Provisions 7
Article IV. Charges For Coverage 8
Article V. Nonpayment, Reinstatement, Termination, Cancellation, Conversion 9
Article VI. Subscriber's Record,Certificate and Identification Card i0
Article VII. Eligibility, Election of Coverage, Effective Date of Coverage, Extension of Coverage,
Waiting Periods
-10
Article VII I. Payment For Services 12
Article IX. Subrogation 12
Article X. Coordination of Benefits 13
Article XI. Additional Provisions 14
Article XII. Basic Coverage For Hospital Services Except Pregnancy 14
Article XIII. Basic Coverage For Doctor's Services Except Pregnancy 15
Article XIV. Pregnancy 17
Article XV. Oral Surgery 18
Article XVI. Mental and Nervous Illness,Drug Addiction and Alcoholism 19
Article XVII. Major Medical Benefits 19
Article XVIII. Outpatient and Doctor's Office Radiology and Pathology Services 22
Group-- UCR 1
•
ARTICLE I. DEFINITIONS
A. RELATING TO THIS AGREEMENT:
1. Benefit Period: A continuous period of Hospital confinement as an Inpatient,or sucessive periods of Hospital
confinement as an Inpatient when the last day of discharge and the following date of admission are separated by less
than sixty (60) consecutive days. When at least sixty (60) consecutive days separate the date of the last discharge
from any Hospital and the next date of admission to any Hospital, another Benefit Period shall be available. In
determining a Benefit Period for the purposes of this Contract, the day of admission shall be counted, but the day
of discharge shall not be counted.
2. Certificate: A form which is not a part of this Contract, issued to the Subscriber which summarizes benefits,
limitations,exclusions,waiting periods,and other information concerning coverage of this Contract.
3. Coinsurance: The percentage of an approved charge for covered services which is the Subscriber's responsibility
to pay.
4. Contract: This agreement between the Company and the Applicant, including any attached endorsements,
the application of the Applicant,and the individual applications of the Subscribers.
5. Contract Year: The twelve (12) consecutive calendar months commencing with the original effective date
of this Contract,and each twelve (12) consecutive months thereafter during the life of this Contract.
6. Covered Services: Care,treatment,facilities, and supplies for which payment is provided for by this Contract.
7. Identification Card: A card issued to a Subscriber, bearing the Subscriber's name and other information con-
cerning coverage provided by this Contract.
8. Medicare: Benefits provided under the Health Insurance for the Aged Act,Title XVIII of the Social Security
Amendment of 1965 as then constituted or later amended.
9. Membership Year: The twelve (12) consecutive months commencing with the original effective date of coverage
of the Subscriber with the Company, and each twelve (12) consecutive months thereafter during the Subscriber's
continuous membership,whether under this or some other Contract with the Company.
10. New Plan: A Membership Agreement to which conversion is offered by this Contract or may otherwise be
permitted by the Company.
11. Schedule of Benefits: A form,which is not a part of this Contract,issued to the Subscriber which summarizes
benefits,applicable time periods,and other information concerning coverage of this Contract,
12. Usual, Customary and Reasonable Fees: •
a; tIsuat=Fee:-The-fee commonly-charged fora given service by an individual Doctor in his personal practice:
b. Customary Fee: The ninetieth (90th) percentile of charges by Doctors of similar training and experience
for the same service within a specific geographic or socioeconomic area.
'e. Reasonable Fee: A fee which meets the-Usual•and Customary criteria, or is justifiable in the special
circumstances of the particular service in question.
13. Waiting Period: A specified number of days during which benefits are not provided for certain conditions
under this Contract.
B. RELATING TO INDIVIDUALS COVERED:
1. Covered Person: A Subscriber or Eligible Dependent of a Subscriber who has a family membership.
Group— UCR 2
2. Eligible Dependent:
a. The Subscriber's spouse unless they are legally and effectively divorced or separated, or their marriage
has been legally and effectively dissolved;
b. The Subscriber's unmarried children under nineteen (19) years of age who are chiefly dependent upon the
Subscriber for support and maintenance;
(1) A child is "chiefly dependent upon the Subscriber for support and maintenance"if,and so long as,
the Subscriber provides more than one-half of the support of such child as support is determined under
the Internal Revenue Code of the United States. Children includes step-children,legally adopted children,
and grandchildren who live with the Subscriber in a regular child-parent relationship, but not foster
children.
(2) Attainment of age nineteen (19) while such child is a Covered Person shall not terminate the
coverage of the child during the continuance of this Contract while the child is and continues to be both
(a) incapable of self-sustaining employment by reason of mental or physical handicap based upon
standards and criteria on file with the Department of Insurance of the State of Nebraska and (b) chiefly
dependent upon the Subscriber for support and maintenance,if proof of such incapacity and dependency
is furnished to the Company by the Subscriber within thirty-one (31) days of the child's attainment of age
nineteen (19) and subsequently as may be required by the Company but not more frequently than
annually after the two (2) year period following the child's attainment of age nineteen (19).
c. The Subscriber's unmarried•children under twenty-four (24) years of age who are chiefly dependent
upon the Subscriber for support and maintenance and who are not regularly employed thirty (30) or more
hours per week and are in regular,full-time attendance at an educational institution which maintains a faculty
and curriculum and has a regularly organized body of students in attendance.
3. Family Membership: Provides coverage for the Subscriber and all Eligible Dependents of the Subscriber.
4. One-Person Membership: Provides coverage for only the Subscriber.
5. Subscriber: Any person who is eligible for coverage as stated in the application for this Contract and has been
so designated to the Company by the Applicant,and who is named on an Identification Card issued by the Company
pursuant to this Contract.
C. RELATING TO TYPES OF CARE AND PHYSICAL CONDITION:
0 t`) � 1. Cosmetic Surgery: Surgery which can be expected to improve the physical appearance of an individual but
��c�.,r Jwhich does not restore or materially improve a bodily function.
•
"`� 2. Custodial/Domiciliary Care: Care provided to a patient (1) who is mentally or physically disabled and such
disability is expected to continue and be prolonged, and (2) who requires a protected, monitored and/or controlled
environment whether in an institution or in the home, and (3) who requires assistance to support the essentials of
daily living, and (4) who is not under active and specific medical, surgical and/or psychiatric treatment which will
reduce the disability to the extent necessary to enable the patient to function outside the protected, monitored
and/or controlled environment. A custodial care determination is not precluded by the fact that a patient is under the
care of a supervising and/or attending physician and that services are being ordered and prescribed to support and
generally maintain the patient's condition, and/or provide for the patient's comfort,and/or assure the manageability
of the patient. Further,a custodial care determination is not precluded because the ordered and prescribed services
and supplies are being administered by a Registered Nurse or Licensed Practical Nurse.
3. Experimental Treatment: Medical care, drugs, or medicine that is essentially investigatory or unproven and
usually provided under controlled medicolegal conditions which does not meet the generally accepted standards
of usual professional medical practice in the general medical community.
4. Illness: Bodily disorder or disease.
Group- UCR 3
5. Injury: Accidental physical harm.
6. Inpatient: A patient who has been admitted to a Hospital for bed occupancy for purposes of receiving
necessary medical care, with the reasonable expectation that the patient will remain in the institution at least
twenty-four(24) hours and with the registration and assignment of an inpatient number or designation.
7. Medical Emergency: The sudden and unexpected onset of a medical condition or the acute exacerbation of a
chronic condition which requires immediate medical treatment and/or which manifests painful symptomatology
requiring immediate efforts to alleviate suffering such as; heart attacks, cardiovascular accidents, poisonings, loss of
consciousness or respiration,convulsions,and such other serious acute conditions as may be determined to be Medical
Emergencies by the Company based upon standards and criteria on file with the Department of Insurance of the
State of Nebraska.
8. Medically Necessary: The level of services and supplies i.e., frequency, extent, and kinds, adequate for the
diagnosis and treatment of Illness or Injury.
9. Outpatient: An individual treated in the Outpatient Department or Emergency Room of a Hospital.
10. Physical Rehabilitation: Services primarily provided to upgrade the patient's ability to function as
independently as possible in the activities of daily living,such as self-sufficiency in bathing,walking,toileting,eating,
dressing,and homemaking.
11. Pregnancy: Includes obstetrics, abortions, threatened abortions, miscarriages, premature deliveries, ectopic
pregnancies,or other conditions or complications caused by or arising from pregnancy.
D. RELATING TO FACILITIES FOR CARE:
1. Contracting Hospital: A Hospital which has contracted with the Company to provide services.
2. Free Standing Ambulatory Facility: A facility for surgical treatment of patients,other than and not connected
with, offices of individual or group practice physicians, not licensed as a part of a Hospital, but providing those
facilities and degree of care generally found in and required cf licensed Hospitals except non-emergency overnight
care,which has contracted with the Company to provide services.
3. Hospital: An institution primarily engaged in providing, for compensation from Inpatients, facilities for the
surgical and medical diagnosis, treatment and care of injured and sick persons by or under the supervision of a staff
of Physicians licensed to practice medicine and surgery,which provides a twenty-four(24) hour-a-day nursing service
by Registered Nurses, and which is not, other than incidentally (1) an institution which has as its primary purposes
the furnishing of food, shelter,training,educational or nonmedical personal services(2) a nursing home or a place for
rest, the aged, drug addicts, or alcoholics or(3) a place for the treatment of mental disorder or for mental or physical
rehabilitation (4) or any other facility,whether operated independently or as part of a'Hospital,which has entered
into a written agreement with the Company based upon controlled care criteria and standards on file with the State
of Nebraska, Department of Insurance,to,provide specific services under the•provisions of such written agreement.
4. Member Hospital:•Either a Contracting or Participating Hospital.
•
5. Non-Member Hospital: A Hospital other than a Contracting or Participating Hospital.
6. Participating Hospital: A Hospital in another state or territory which contracts with a Blue Cross Plan in
its area which participates in the National Blue Cross Inter-Plan Service Benefit Bank.
E. RELATING TO MEDICAL PERSONNEL:
1. Contracting Doctor: Any Doctor with whom the Company has entered into a written agreement with regard
to payment for services covered by this Contract.
2. Doctor: Any Physician or any other duly licensed practitioner of the healing arts to or for whom benefits
are required to be paid by the statutes of the State of Nebraska or by direction of the Board of Directors of the
Company.
Group- UCR 4
•
3. Physician: Any person duly authorized to practice medicine and surgery by the state, territory, province,
district,or country where the medical or surgical services are performed.
ARTICLE II. EXCLUSIONS AND LIMITATIONS
A. No payments shall be made by this Contract except as provided by Article XVII or otherwise stated herein for:
1. Services not specifically provided by this Contract and any endorsements hereto,nor in any amounts in excess
of charges for services provided by this Contract and any endorsements.
2. Any services for,or relating to,or which are,any of the following:
a. Allergy skin testing and injections except as provided by Article XVII;
b. Audiological examinations or hearing aids and their fitting;
c. Blood, blood plasma or blood derivatives or blood fractionates,or services by or for blood donors,except
administrative charges for blood furnished to a Hospital by the American Red Cross and used for a Covered
Person;
d. Cosmetic or restorative surgery except that required as a result of an accident occurring aft the effective
of coverage; '9� CC S ,N�(�u, ,2.�v b�-<-1- 41 F. o--t C-
e. Detection or correction by manual or mechanical means of structural imbalance, distortion, or subluxa-
�`"�o( tion in the human body for the purpose of removing nerve interference and the effects thereof where such
interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;
f. Eye refractions,eyeglasses or contact lenses except as provided by Article XVII;
g. Hospital or Physician charges for stand-by availability;
Yam .
h. Immunizations except as provided by Article XVII;
i. Personal expenses while hospitalized, such as guest meals,TV rental and barber services;
j. Routine or periodic physical examinations;
k. Treatment primarily for obesity or for weight reduction,except surgical operations;
I. Therapy which is primarily of an occupational, recreational or educational nature, or forms of non-
medical self-care or self-help training,and any related diagnostic testing;
m. Treatment or removal of corns, callosities, the cutting or trimming of nails.
3. Any service for,or relating to,or which is,any of the following:
a. Not considered by the Company, either initially or after a period of convalescence or treatment, to be
medically necessary for diagnosis or treatment of an Illness, Injury or Pregnancy,or which is not consistent with
the diagnosis or treatment of a condition for which medical care is necessary;
b. Not specifically covered but is provided pursuant to accreditation requirements of any Hospital or
Hospital staff rules or regulations;
Group- UCR 5
•
c. Provided by a person, firm or corporation, required by the Nebraska Health Care Certificate of Need
Act to have obtained a certificate of need as therein defined, who or which has not in fact obtained such
certificate;
d. Provided if admission to a Hospital as an Inpatient or continued hospitalization is primarily for any or
all of the following:
(1) Diagnostic studies, such as radiology, pathology or similar tests, not requiring hospitalization;
(2) Physical rehabilitation, except when confined to a Hospital which has specifically contracted with
the Company to provide such treatment;
(3) Custodial/Domiciliary care.
e. Treatment not provided in accordance with accepted professional medical standards in the United States;
f. Procedures which have become obsolete unless, in the opinion of the Company, such treatment is justi-
fied. A list of such obsolete procedures shall be maintained on file with the State of Nebraska,Department of
Insurance.
g. Treatment, drugs, medicines and procedures which in the opinion of the Company are experimental_
4. Services provided to or for:
a. Any dependent of a Subscriber who has One-Person Membership;
•
b. Any dependent who does not meet the definition of an Eligible Dependent of a Subscriber who has
Family Membership;
•
c. Any Covered Person before the effective date of coverage;
d. Any Covered Person for any condition, including Pregnancy, for which coverage has not yet become
effective because of the waiting periods set forth herein.
5. Interest or sales or other taxes applicable to services for which payment may be made by this Contract.
6. Charges by Hospitals or Doctors for filling out claim forms or furnishing any other information or reports.
7. Charges by Hospitals or Doctors while the patient is temporarily dismissed or released from the Hospital.
8. Services for Illness or Injury either caused directly or indirectly, in whole or in part,by war or any act of war,
declared or undeclared,or sustained by a Covered Person while performing military service. _
9. Services provided a Covered Person in or by a Non-Member Ho
spital except as specifically provided for in
Article XII (Basi
c c Coverage for Hospital
g p Services Except Pregnancy) and Article XIV (Pregnancy).
10. A Subscriber or Eligible Dependent with another Blue Cross and Blue Shield Coverage shall be limited to
payment for not more than one-hundred percent (100%) of the covered charge with the coverage having the earliest
effective date paying first.
11. Services provided in or by (1) a Veterans Administration Hospital or (2) any Non-Member Hospital or other
institution which is owned, operated or controlled by the United States,a state,a coup other governmental go rnmental units,
subdivisions or districts,hospital authorities,or any agencies thereof.
12. Services provided for any Illness, Injury or Pregnancy if such services are available, in whole or in part, at
governmental expense,whether or not the Covered Person elects to receive such benefits,except as follows:
Group- UCR 6
•
a. With respect to persons who are eligible for benefits under Medicare, whether or not such person is
enrolled under Medicare, the obligation of the Company to provide benefits will be reduced under all circum-
stances by the amount of payment or benefits such person receives or would have received under Medicare.
b. With respect to persons who are eligible for benefits under any other governmental program,whether or
not the person is enrolled thereunder, the obligation of the Company to provide benefits will be reduced under
all circumstances by the amount of payments a Covered Person is eligible for under the governmental program;
and all such payments and benefits shall be charged against the maximum benefit payments as if such benefits
had been provided by this Contract, except as otherwise provided by Article X (Coordination of Benefits).
13. Services to the extent they are not payable by this Contract because of the application of Article X (Coord-
ination of Benefits).
14. Services for which there is no legal obligation to pay, or for which no charge would be made to the Covered
Person if coverage hereunder did not exist. Any charge which exceeds the charge that would have been made if no
coverage existed, or any charge made which is normally or customarily furnished without payment shall be treated as
a charge for which there is no legal obligation to pay.
15. Services for conditions arising out of and in the course of employment which any employer is required to
furnish or make payment for, in whole or in part, under the provisions of any federal, state or other applicable law
(commonly called Worker's Compensation Laws), or any similar law which may be made applicable;or such Services,
in whole or in part,to which a Covered Person may be entitled by complying with such laws although the Covered
Person elects to waive or does not assert his or her rights thereunder;or such services for which a Covered Person has
received compensation from any employer or employer's insurer,in the form of a Worker's Compensation settlement
or otherwise.•
B. Subject to all other conditions of this Contract,limited service is provided for:
1. Oral Surgery (Article XV).
2. Mental and Nervous Illness,Alcoholism,and Drug Addiction (Article XVI).
C. For waiting periods,refer to Article VII of this Contract.
ARTICLE Ill. STANDARD PROVISIONS
A. ENTIRE CONTRACT CHANGES: This Contract constitutes the entire contract of insurance. No change in this
Contract shall be valid until approved by an executive officer of the Company and unless such approval be endorsed hereon
or attached hereto. Any such valid amendment, however, shall be binding upon all persons covered under this Contract
whether they become covered before or after the effective date of the amendment.The Company reserves the right to,and
it is agreed that it may,expand the scope of benefits to include payment for newly developed or additional services under
such arrangements with the providers of such services as the Company shall determine, if it appears to the Company that
such services will result either in containing costs or improving the quality of services received and such expansion of the
scope of benefits shall not be considered or construed as an amendment to this Contract.
B. CERTAIN DEFENSES: All statements, in the absence of fraud, made by the Applicant or any Subscriber shall be
deemed representations and not warranties, and no such statements shall void coverage or reduce benefits hereunder unless
contained in the Application as attached hereto or the application of the Subscriber as filed with the Company.
C. NOTICE OF CLAIM: Written notice of claim must be given to the Company within thirty (30) days after receipt of
services upon which a claim is to be based, or as soon thereafter as is reasonably possible. Notice given by or on behalf of
the Subscriber or any Eligible Dependent to the Company at the address stated in Paragraph H below or to any authorized
agent of the Company, with information sufficient to identify the Subscriber shall be deemed notice to the Company.
Failure to give notice within the time provided shall not invalidate or reduce any claim if it shall be shown not to have been
reasonably possible to give such notice and that notice was given as soon as was reasonably possible.
Group- UCR 7
D. CLAIM FORMS: The Company, upon receipt of a notice of claim, will furnish to the provider of service or the
Subscriber, as may be appropriate, such forms as are usually furnished by it for filing proofs of loss. If such forms are not
furnished within fifteen (15) days after the giving of such notice,the Subscriber shall be deemed to have complied with the
requirements of this Contract as to proof of loss upon submitting, within the time fixed herein for filing proofs of loss,
written proof covering the occurrence,the character and the extent of the loss for which claim is made.
E. PROOFS OF LOSS: Written proof of loss must be given to the Company at the address stated in Paragraph H below
within ninety (90) days after the date of such loss. Failure to furnish such proof within the time required shall not
invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is
furnished as soon as reasonably possible and in any event, except in the absence of legal capacity, within one (1) year
from the time proof is otherwise required.
F. TIME OF PAYMENT OF CLAIMS: All money payable by this Contract shall be paid immediately upon receipt
of.due written proof of such loss.
G. LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this Contract prior to the expiration
of sixty (60) days after written proof of loss has been furnished in accordance with the requirements of this Contract. No
such action shall be brought after the expiration of three (3) years after the time written proof of loss is required to be
furnished.
H. ADDRESSES FOR NOTICE: Any notice given under this Contract shall be sufficient if given to the Applicaa
when addressed to it at the office(s) stated in the attached application; if given to the Company,when addressed to it at
7261 Mercy Road, Omaha, Nebraska 68124;if given to the.Subscriber when addressed to the Subscriber at the Subscriber's
most recent address as it appears on the records of the Company.
I. CHANGE OF OCCUPATION: No reduction shall be made in any coverage herein provided by reason of any change
in the occupation of the Subscriber or any Eligible Dependent, except under the provisions of this Contract relating to
the attendance of the Subscriber's unmarried children at educational institutions.
J. UNPAID PREMIUM: Upon the payment of a claim by this Contract, any premium then due and unpaid or covered
by any note or written order may be deducted therefrom.
K. CONFORMITY WITH STATUTES: Any provision of this Contract which, on its effective date, is in conflict
with the statutes of the State of Nebraska or the laws of the United States of America is hereby amended to conform to
the minimum requirements of such statutes.
ARTICLE IV. CHARGES FOR COVERAGE
A. The charges for this Contract are the sum of the rates for the respective services provided herein.
B. The rates shown in the Application shall be used in computing the sum due under this Contract, provided that
the Company may,on any of the following dates,establish for any of the services hereunder a new rate upon which further
charges shall be computed: (a) on any charge due date after the first Contract Year, provided that the Company notifies
the Applicant or its Agent of Record at least thirty (30) days in advance of such charge due date (b)whenever the terms of
this Contract are changed. The parties hereto agree that the above-mentioned rates may be changed upon thirty (30) days
notice given pursuant to Article III, Paragraph H of this Contract, if in the opinion of the Company,the cost of providing
services and the administration thereof so requires.
C. The charge shall equal the sum of the applicable monthly rates for all One-Person and Family Memberships to be
covered as of the due date unless the parties mutually agree upon some other method of computation.
D. Adjustments which involve a refund of charges to the Applicant shall be limited to the period of twelve (12) months
immediately preceding the date of receipt by the Company of evidence that such adjustment should be made.
E. All charges for this Contract, including any adjustments, are payable by the Applicant on or before their respective
due dates specified herein, at the Company's home office in Omaha, Nebraska. The payment of any charges shall not
maintain the coverage of this Contract in force beyond the day immediately preceding the next due date, except as
otherwise provided herein.
Group-UCR 8
-
ARTICLE V. NONPAYMENT, REINSTATEMENT,TERMINATION, CANCELLATION, CONVERSION
A. A grace period of thirty-one (31) days,without interest,will be allowed for payment of-any charge due after the first
charge due date, during which period this Contract shall continue in force if the Applicant pays the past due charges during
• said grace period,subject to the other provisions set forth in this Article.
B. If the Applicant fails to pay the past due charges during said grace period, this Contract shall terminate as of 12:00
Midnight of the last day for which charges have been paid.
C. If any renewal premium is not paid within the time granted for payment,a subsequent acceptance of premium by the
Company or by any agent duly authorized by the Company to accept such premium,without requiring in connection there-
with an application for reinstatement, shall reinstate the Contract;provided,that if the Company or such agent requires an
application for reinstatement and issues a conditional receipt for the premium tendered, the coverage will be reinstated
upon approval of such application by the Company or, lacking such approval, upon the forty-fifth (45) day following the
date of such conditional receipt unless the Company has previously notifed the Applicant or Subscriber,as the case may be,
in writing of its disapproval of such application. The reinstated coverage shall include only loss resulting from such injury as
may be sustained after the date of reinstatement and loss due to such illness as may begin more than ten (10) days after
such date. In all other respects,the parties shall have•the same rights hereunder as they had immediately before the due
date of the defaulted premium,subject to any provisions endorsed hereon or attached hereto.
D. If this Contract terminates for any reason, payments shall not be made under this Contract for any services provided
on or after the effective date of such termination,including any services provided for Pregnancy.
•
E. If the Applicant notifies the Company that the coverage of any Subscriber under this Contract is to be terminated
or does not remit the required charges for coverage for or on behalf of said Subscriber, the coverage respecting such
Subscriber and any Dependents shall terminate automatically at the end of the period for which the charges specified herein
shall have been paid by the Applicant for such Subscriber,and no grace period shall apply.
F. If coverage terminates for any reason, payments shall not be made for any services provided to or for any formerly
covered person on or after the effective date of such termination,including any services provided for Pregnancy.
G. No payments shall be made for services provided to or for any person on or after the date such person ceases to be
an Eligible Dependent,including services provided for Pregnancy.
H. The Company may cancel this Contract at any time by written notice delivered or mailed to the Applicant at the most
recent address as it appears on the records of the Company stating when, not less than five (5) days thereafter, such
cancellation shall be effective; and after this Contract has been continued beyond its original term, the Applicant may
cancel this Contract at any time by written notice delivered or mailed to the Company, effective upon receipt or on such
later date as may be specified in such notice. In the event of cancellation,the Company will return promptly the unearned
portion of any premium paid,computed pro rata. Cancellation shall be without prejudice to any claim for services provided
before the effective date of cancellation.
I. If the Applicant cancels or terminates this Contract, or if the Applicant executes a contract with another health care
carrier or becomes self-insured,no conversion privileges shall apply except at the option of the Company.
• J. If the Applicant notifies the Company that the coverage of any Subscriber covered under this Contract is to be
terminated because of the termination of the relationship between the Applicant and the Subscriber,the Company will issue
continuous converted coverage to such terminated Subscriber provided such Subscriber makes application for such coverage
and makes payment of the initial charges therefor within thirty-one (31) days of the date of termination.
K. In the event of the death of a Subscriber leaving a surviving spouse and having a Family Membership,the Company
will issue continuous converted coverage to the Eligible Dependents of such Subscriber,provided the surviving spouse makes
application for such coverage and makes payment of the initial charges therefor within thirty-one (31) days of the date of
the Subscriber's death.
L In the event of the death of a Subscriber not leaving a surviving spouse and having a Family Membership, or in the
event a child of a Subscriber having a Family Membership ceases to be an Eligible Dependent, the Company will issue
Group- UCR 9
.
•
continuous converted coverage to the child or children of such Subscriber,provided such child or children make application
for such coverage and make payment of the initial charges therefor within thirty-one (31) days of the date of the
Subscriber's death or the cessation of eligibility,as the case may be.
M. If the individual having a conversion privilege hereunder was covered under a Family Membership and would other-
wise be eligible for a Family Membership,then conversion may be to either a Family Membership or a One-Person Member-
ship as the individual may elect. If the individual having a conversion privilege hereunder was not covered under a Family
Membership, then conversion may only be to a One-Person Membership, or to a Family Membership subject to such
conditions or waiting periods as the Company may require.
N. The New Plan shall be such plan as the Company may offer as appropriate to the situation,to be determined by the
Company.
O. Benefits provided, persons covered,and all other terms and conditions thereof,including rates,shall be in accordance
with the rules of the Company for the New Plan. It is acknowledged that the benefits available in this Contract,particularly
in such areas as dental, vision and hearing care, major medical coverage, and other coverages provided by endorsement to
this Contract may not be included or may not be as extensive in the New Plan.
P. Any waiting period required by the New Plan shall be reduced only by the length of time the individual converting
has been continuously covered by the Company.
Q. Benefits are not payable under the New Plan until services are provided while covered under the New Plan. However,
if hospitalized on the date of change,hospital benefits for that admission will be provided by this Contract.
R. Failure to make the application for the New Plan or to make payment of the initial charges therefor,or both,within
the time limits fixed above,shall cause all rights and privileges of conversion to lapse.
ARTICLE VI. SUBSCRIBER'S RECORD, CERTIFICATE AND IDENTIFICATION CARD
A. The Applicant shall provide to the Company such information about eligibility of persons becoming covered,changes
in coverage, and termination of coverage, as the Company may require for the administration of this Contract.Such of the
Applicant's records as may, in the opinion of the Company,relate to coverage hereunder shall be open to the Company for
review at any reasonable time.
B. If erroneous information is furnished to the Company which affects the fact or amount of coverage of any Covered
Person, the determination of the extent to which such Covered Person is or was covered shall be based upon the correct
facts.
C. The Company will issue to or for each Subscriber an Identification Card,a Certificate of Coverage and a Schedule of
Benefits.
ARTICLE VII. ELIGIBILITY, ELECTION OF COVERAGE, EFFECTIVE DATE OF COVERAGE, EXTENSION OF
COVERAGE,WAITING PERIODS
A. ELIGIBILITY:
1. If the Applicant is, and applies as, an employer, then every employee of the Applicant shall be eligible for
coverage under this Contract,subject to any conditions stated in the Application.
2. Otherwise, eligibility for coverage under this Contract is subject to the conditions stated in the Application.
3. Eligibility of dependents is subject to their meeting, and continuing to meet,the definition of Eligible Depend-
ent in Article I.
B. ELECTION OF COVERAGE:
1. Any individual eligible for coverage may elect a type of membership as provided in the Application by complet-
ing and filing with the Applicant an individual application form furnished by the Company or Applicant.
Group- UCR 10
•
•
2. Any Subscriber may change from one type membership to another by filing with the Applicant a Request For
Change Form furnished by the Company or Applicant.
C. EFFECTIVE DATE OF COVERAGE: Subject to any probationary period for eligibility in the Application, to the
delivery of the completed application form or Request For Coverage Form to the Company by the Applicant,to the passage
of any required waiting periods and to paragraph D below coverage hereunder shall commence as follows:
1. For a person eligible on the initial Effective Date of this Contract whose application for coverage is received by
the Company on or before that date,coverage shall begin on the initial Effective Date of this Contract.
2. For any person not eligible or who has not elected coverage on the initial Effective Date of this Contract,but
eligible thereafter, coverage shall begin on the next monthly due date for the group following receipt of the
Subscriber's application by the Company.
3. If a Subscriber changes to Family Membership, coverage of the Subscriber's Eligible Dependents shall begin on
the next monthly due date of the group following receipt by the Company of the Request For Change Form,except
that a newly-married Subscriber may backdate the Family Membership to the last monthly due date of the group
before the marriage if the Request For Change Form is received by the Company within thirty (30) days of the
marriage.
4. For newborn children of a Subscriber who had previously elected Family Membership, coverage of Injury or
Illness (including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities)
shall begin immediately.
5. Coverage under this Contract for any person confined in a Hospital,convalescent hospital,or place of treatment
for drug addiction or mental illness or alcoholism on the effective date, shall not begin until 12:01 A.M. on the day
after dismissal therefrom.
D. EXTENSION OF COVERAGE: Coverage under this Contract may be extended to individuals not now designated
as eligible by the Applicant at such times and upon such terms as may be agreed to between the Applicant and the
Company.
E. WAITING PERIODS:
1. Subject to any waiver stated in the Application, no payment shall be made under this Contract for a Covered
Person for the following conditions or procedures unless the service is provided more than two-hundred seventy (270)
days after continuous coverage of the Covered Person:
a. Sterilization, tonsillectomy, appendectomy, adenoidectomy, impacted teeth, myringotomy or
tympanoplasty;
b. Colporrhaphy, colpoplasty, cystocele (repair of anterior vaginal wall), perineorrhaphy, perineoplasty,
rectocele (repair of posterior vaginal wall), total or partial salpingectomy, total or partial oophorectomy,
hysterectomy,or myomectomy;
c. Inguinal, umbilical or femoral hernias, acne, hemorrhoids, varicose veins,duodenal or gastric ulcers, gall
bladder disease,including gallstones,medical or surgical treatment of thyroid disease;
d. Preexisting conditions,which are defined as:
1) Any Illness or reoccurrence thereof or complications therefrom, whether known or unknown to
the Covered Person, which may be considered from a medical standpoint to have been present in any
form on or before the Effective Date of coverage, including, but not limited to, any illness, for which
medical or surgical treatment or advice was received at any time before the first date of coverage.
2) Any Injury or complications therefrom or reoccurrence thereof, caused by an accident occurring
before the first date of coverage.
Group-UCR 11
•
3) Pregnancy or any complications therefrom, unless normal childbirth would have occurred after
two-hundred seventy (270) days of continuous maternity coverage.
e. Congenital anomalies and birth abnormalities,which are defined as conditions existing at or from birth
and which are a significant deviation from the common form or norm, including, but not limited to, ear
deformities, harelip, birthmarks, webbed fingers or toes, or other conditions which may be reasonably
determined by the Company to be congenital anomalies or birth abnormalities, except as coverage is provided
under paragraph C.4.,above.
•
2. Persons who fail to elect coverage within thirty-one (31) days of eligibility will be required to observe the
waiting periods stated above.
ARTICLE VIII. PAYMENT FOR SERVICES
A. All payments,except those due under Major Medical,for Covered Services provided by Member Hospitals or Contract-
ing Doctors shall be made directly to such providers.
B. In all other cases, payments shall, at the option of the Company, be made either to the Subscriber or the provider.
C. No assignment of any amounts payable under this Contract shall be recognized or accepted by, or binding upon,
the Company.
•
D. The Company shall be entitled to recover payments made by the Company for services not covered by this Contract,
to the extent and in the manner provided by law.
E. Payment by the Company for services not covered by this Contract shall not make the Company liable for further
payment for the same Illness,Injury or Pregnancy not otherwise covered.
F. The obligation of the Company to seek recovery of payments from a Covered Person or provider which are, or
appear to be in excess of the requirements of this Contract,or otherwise due the Company,shall be limited to reasonable
efforts under all the circumstances. Such excess payments not recovered shall be charged as benefits paid under this
Contract, and the Company shall be discharged from all liability therefore by the exercise of such reasonable efforts.
G. In the event of any dispute with respect to the application or interpretation of any provision of this Contract,the
Subscriber may appeal the Company decision by requesting a review by the Claims and Inquiries Division, Nebraska Depart-
ment of Insurance, Lincoln,Nebraska 68509.
ARTICLE IX. SUBROGATION
A. Subrogation is the limited right of the Company to be substituted for a Covered Person or Subscriber with regard to
a claim for damages for willfully or negligently caused,injuries.
B. If payment is made for a Covered Person under this Contract, the Company, to the extent of such payment,shall
be subrogated to all the rights of recovery which the Covered Person or Subscriber or anyone on their behalf may have
against any person or organization or any liability insurer except a No-fault Automobile Insurance carrier.
C. The Covered Person or Subscriber shall execute and deliver such documents as the Company may require, shall do
whatever else is reasonably required to secure such rights to the Company, and shall do nothing after loss to prejudice
such rights.
Group- UCR 12
410
ARTICLE X. COORDINATION OF BENEFITS
A. The purpose of this Article is to coordinate the payment for services under this Contract with the payment for the
same services under other health benefits,including No-fault Automobile Insurance coverages,in order to ultimately reduce
the cost of the coverage provided by this Contract.Within this Article,the following definitions apply:
1. Health Benefits Insurance: All forms of insurance under which payment is made for hospital,medical,or other
health care services and supplies.
2. No-fault Automobile Insurance: Automobile insurance under which benefits are payable by the insurer for the
expenses of hospital and medical care of injuries resulting from an automobile accident without regard to whose
negligence caused the accident.
3. Health Benefits Coverage: Both Health Benefits and No-fault Automobile Insurance, to the extent Coordin-
ation of Benefits as herein provided for is not.prohibited by law.
4. Primary Carrier: The Company, unless one or more other insurers are the Primary Carrier under any of the
following rules,in which case the Company shall not be the Primary Carrier:
a. In the event benefits are payable under No-fault Automobile Insurance,the no-fault automobile insurer
shall be the Primary Carrier if it is obligated to paybenefits for health care without
regard to other Health
Benefits Coverage. •-
b. In the event benefits are payable under any other Health Benefits Coverage which does not provide for
Coordination of Benefits,the insurer providing such other Health Benefits Coverage shall be the Primary Carrier.
c. Whenever the benefits payable under any other Health Benefits Coverage other than this Contract are
determined with regard to the benefits payable under this Contract, then the Primary Carrier shall be the
organization which is the only one which satisfies the first one of the following tests by providing Health
Benefits Coverage to the Covered Person:
(1) as an employee,annuitant,member of an organization or student;
(2) as a child or spouse of a male employee,annuitant,member of an organization or student;
(3) under coverage by which the Covered Person has been covered the longer period of time.
B. The amount of benefits otherwise available to a Covered Person under this Contract shall be limited, if the Covered
Person is entitled to benefits under a Health Benefits Coverage other than this Contract and the Company is not the Primary
Carrier, to an amount not to exceed the difference between the reasonable charges to or for the Covered Person and the
benefits payable by the Primary Carrier.
C. The amount of benefits otherwise available to a Covered Person under this Contract shall be limited, if the Covered
Person is entitled to benefits under a Health Benefits Coverage other than this Contract whether with the Company or with
some other carrier and it cannot be determined whether or not the Company is the Primary Carrier,to an amount not to
exceed that amount which is computed by determining the ratio which benefits otherwise available to the Covered Person
by this Contract bear to the total benefits available to the Covered Person, and multiplying the amount of reasonable
charges to or for the Covered Person by that ratio.
D. If the Company is the Primary Carrier,there shall be no reduction of the benefits otherwise available to a Covered
Person under this Contract.
E. The obligation of the Company to administer this Article is limited to making a reasonable effort to avoid liability
as the Primary Carrier in appropriate cases brought to its attention;to making such efforts as it shall determine reasonable
to compute the amount payable under any other Health Benefits Coverage;and to making such efforts as it shall determine
reasonable to recover any excess payments made by it.
Group— UCR 13
F. Whenever payments which should have been made under this Article have been made under any other Health Benefits
Coverage, the Company shall have the right, exercisable alone and in its sole discretion,to pay over to any organization
making such other payments any amounts it shall reasonably determine to be warranted in order to satisfy the intent of this
Article, and amounts so paid shall be deemed to be benefits paid under this Contract and,to the extent of such payments,
the Company shall be fully discharged from liability under this Contract.
ARTICLE XI. ADDITIONAL PROVISIONS
A. Hospitals contracting with the Company have an obligation, under the laws of the State of Nebraska, to provide
hospital services in accordance with the provisions of this Contract. It is expressly agreed that the Company does not
undertake to furnish covered services, but only to assume on behalf of the Covered Person,the cost thereof,to the extent
herein provided. The Company is in no event liable for any act,error,or omission of any Hospital,Doctor or other provider
or any agent or employee of any Hospital,Doctor,or other provider.
B. Any admission to a Hospital as an Inpatient must be upon order of a Doctor acceptable to the Hospital and all services
furnished by a Hospital must be ordered by a Doctor. All services furnished by a Hospital, including emergency room
services, are subject to the availability of facilities at the Hospital selected and to its rules and regulations,including those
governing as go g admissions well as the type and scope of services furnished by it.
C. In consideration of waiving physical examinations of Covered Persons and as a condition precedent to the approval
of claims hereunder,the Company shall be entitled to receive,to such extent as may be lawful,from attending or examining
Doctors or from Hospitals or others providing-Covered Services hereunder, such information, records and reports relating
to attendance to or examination of or treatment provided Covered Persons as may be required for the administration of
such claims, provided however,that the Company shall in every case hold such data as confidential.
D. The Annual Meeting of Members of the Company is held at its home office in Omaha,Nebraska,at 4:00 P.M. on the
second Monday of February of each year. Each Subscriber covered hereunder is a Member of the Company and is entitled
to vote on all matters coming before any Annual or Special Meeting of the Company. It is agreed, in the absence of a
Subscriber from any such Meeting,that any other Subscriber may be appointed as the Subscriber's proxy provided a written
proxy is filed with the Secretary of the Company at least five (5) days before the meeting. In the absence of the Subscriber
or his duly filed proxy,the President of the Company, or in the absence of the President,the Treasurer,shall be the proxy
of such Subscriber to vote in his place and stead on all matters corning before any such Meeting of the Members.The proxy
shall be valid for so long as this Contract remains in force unless the Subscriber shall revoke it at any time befcre its
exercise.
ARTICLE XII. BASIC COVERAGE FOR HOSPITAL SERVICES EXCEPT PREGNANCY
A. INPATIENT SERVICES:
1. Member Hospitals: If, by reason of Illness or Injury a Covered Person is confined as an Inpatient in a Member
Hospital, payment will be made to the Member Hospital for services which are billed by the Member Hospital as a
regular Hospital service, for not to exceed the number of days per Benefit Period stated in the Application for this
Contract as follows:
a. The specific amount stated in the Application for this Contract for room and board (which shall include
special diet and general nursing service) will be applied to any type of room accommodation not to exceed
the actual charge of the Hospital. If the amount stated in the Application is"Semi-Private,"then the Company
will pay the amount charged for semi-private, or reasonably medically necessary for intensive or cardiac care
and similar type room and board accommodations. When a Covered Person is confined to a private room under
"Semi-Private" coverage, the amount payable shall not exceed the average charge for two (2) bed accommoda-
tions in the Hospital of confinement, unless the patient is confined to a private (isolation) room to prevent
contagion and the Company determines that isolation for that purpose is medically necessary. If confinement
is in a Hospital which has all private (one-bed) rooms, the Company will pay ninety percent (90%) of the
charge for the private room under"Semi-Private"coverage unless otherwise specified in the agreement between
the Company and the Hospital.
Group — UCR 14
b. Use of operating,cystoscopic,cast,recovery and other surgical treatment rooms and equipment.
c. Anesthetics, inhalation therapy, oxygen, and their administration when performed by a Hospital
employee.
d. Drugs, intravenous solutions, vaccines, biologicals, and medicines which are prescribed for and admin-
istered to the Covered Person while hospitalized.
e. Administration of intravenous solutions, blood, blood plasma, blood derivatives, or blood fractionates.
f. Supplies, materials and equipment, including dressings, splints and plaster casts, but excluding "take-
home"drugs and supplies,and convenience items.
g. Radiology and Pathology services when billed by the Hospital.
h. Physical or speech therapy when provided by a Certified Physical or Speech Therapist as an employee of
the Hospital,if the therapy is related to the primary condition for which the patient is hospitalized.
2. Non-Member Hospitals: Benefits will be provided for up to thirty (30) days for Inpatient care in a Non-Member.
Hospital and payment will be made directly to the Subscriber when either of the following conditions apply:
a. Emergency admissions until the patient is medically able to be transferred to a Member Hospital wharf a
Member Hospital is located within a twenty-five (25) mile radius of the Non-Member Hospital.
b. There is no Member Hospital within twenty-five (25) miles of the Non-Member Hospital.
B. OUTPATIENT HOSPITAL SERVICES AND FREE STANDING AMBULATORY SERVICES:
1. The actual charge of a Hospital for Outpatient Services or a Free Standing Ambulatory Facility which has
contracted with the Company will be paid for the services itemized in Subsections b through g of Part A above
provided such services are, in the opinion of the Company, medically necessary for the specific conditions being
treated and are provided for: (1) initial treatment of injuries when provided within seventy-two (72) hours of
the time of the accident (2) surgary (3) th^_ initial care of a Medical Emergency when provided within twenty-four
(24) hours of its onset (4) rabies injections (5) cancer chemotherapy (6) renal dialysis (7) treatment of burns and
(8) reapplication or adjustment of casts.
2. Payment will be made for the services itemized in Subsection g of Part A above if provided within ninety-six
(96) hours, efore an Inpatient admission for previously scheduled surgery.
doc--ems e�c,
C. DEDUCTIBLES AND COINSURANCE:
•
When applicable, the amount payable under this Article will be reduced by the Deductible amount and/or the
Coinsurance percentage stated in the Application.
ARTICLE XIII. BASIC COVERAGE FOR DOCTOR'S SERVICES EXCEPT PREGNANCY
A. DETERMINATION OF PAYMENT:
1. All payments made under this Article for services provided in Nebraska will be based on the Usual,Customary
and Reasonable charge.
2. All payments made under this Article for Covered Services not provided in Nebraska will be based on the Usual,
Customary and Reasonable charge for the specific geographical area if such data is available to the Company. If such
data is not available, payment will be based on the Customary or Reasonable charges made by Doctors in Nebraska.
3. In order for a Covered Person not to be responsible for charges in excess of the Usual, Customary and
Reasonable charge,the Covered Person must:
Group— UCR 15
a. Have the Covered Services performed by a Contracting Doctor;
b. At the time services are requested, or in an emergency or accident case, as soon thereafter as reasonably
possible, advise the Contracting Doctor of coverage by presenting the Identification Card issued to the
Subscriber;
0 Not enter into an agreement with the Contracting Doctor before the date the service is provided for a
specific charge in excess of the Usual,Customary and Reasonable charge.
'�4 When a Contracting Doctor provides a Covered Service and charges an amount greater than the Usual and
Customary charge and the Covered Person has met the above requirements,the Company will take such action as is
set forth in the Agreement between the Company and the Contracting Doctor to reduce the amount to be paid by
the Company,and the Covered Person shall not be required to pay such excess charge.
5. No payment will be made under this Article which exceeds the actual charge of the Doctor.
6. Any charge by a Doctor other than a Contracting Doctor which exceeds the payment provided by this Article
is the responsibility of the Covered Person.
B. BASIC DOCTOR SERVICES COVERED
1. Surgery: Payment will be made for Covered Services provided by the Doctor in charge of the case.consisting-of
operative and cutting procedures and the treatment of fractures and dislocations and such Covered.Services shall
include such surgery and normal preoperative and postoperative care of a Hospital Inpatient, and normal
postoperative care if the Covered Person is not hospitalized.
a. When multiple or bilateral surgical procedures which add significant time or complexity to patient care
are performed at the same operative session, the total benefits shall be the amount payable for the major
procedure plus: (1) fifty percent (50%) of the amount payable for the secondary procedure if only one incision
is required,or (2) seventy-five percent (75%) if a separate incision is required.
b. When an incidental procedure such as an incidental appendectomy,lysis of adhesions,excision of previous
scar, or puncture of ovarian cyst, is performed through the same incision as for other surgery, the amount
payable shall not exceed ten percent (10%) of the normal surgical allowance for the incidental surgery.
c. When a surgical procedure is performed in two or more steps or stages, payment will be limited to the
amount provided for a single procedure.
2. Surgical Assistance: Payment not to exceed twenty percent (20%) of the amount payable for surgery will be
made for surgical assistance by a Doctor who actively- assists the operating Doctor in the performance of certain
surgical procedures. Major surgical procedures .for which coverage is provided for surgical assistance are those
specifically identified in a Schedule -of Allowable Assistant at Surgery Procedures on file with the Department of
Insurance of the State of Nebraska.
3. Anesthesia: Payment will be made for services for anesthesia when personally administered by a Doctor.
Anesthesia services shall include preoperative and postoperative visits and the administration of fluids or blood
incident to the anesthesia or surgery, but shall not include administration of anesthesia by the attending or assisting
surgeon (except spinal,digital,saddle or caudal blocks) nor local infiltrations by whomsoever administered.
4. Non-Surgical Inpatient Hospital Visits: Payment will be made for services for necessary non-surgical care or
treatment of a condition other than that for which surgical care is required for up to the number of days in each
Benefit Period as stated in the Application when a Covered Person is confined as an Inpatient in a Hospital. If surgery
is performed by other than the admitting Doctor,the admitting Doctor is eligible for payment of Hospital visits up to
the date of surgery.
5. Concurrent Inpatient Hospital Visits: Payment for Inpatient Hospital visits covered by Paragraph 4 are provided
when performed by two or more Doctors on the same day if in the opinion of the Company the services are:
Group— UCR 16
a. For a non-surgical medical problem which requires the services and skill of two or more Doctors.
b. Necessary because of medical complications requiring non-surgical care not related to surgery and not
constituting a part of the usual, necessary and related preoperative and postoperative care and requiring
supplemental skills not possessed by the attending surgeon or his assistants.
6. Inpatient Consultation Service: When a Covered Person is an Inpatient, payment will be made for services
provided by a consulting Doctor when requested by the Doctor in charge of the case and when the patient's condition
requires special care or knowledge not possessed by the attending Doctor. Consultation charges are payable only once
fpr each medical specialty for each Hospital confinement. No payment shall be made if the consulting Doctor prof/ides
other services which are payable under this Contract during the same period of confinement.
7. Radiation Therapy: Payment will be made for Inpatient or Outpatient Roentgen therapy or implantation of
radium or radon, but not for Grenz Ray or ultraviolet treatments nor for teleradeotherapy.
8. Tissue Examinations: Payment will be made for tissue examinations in connection with surgical procedures,
whether performed in a Hospital Inpatient or Outpatient facility or in the Doctor's office.
9. Pap Smears: Routine Pap smear test payments are limited to one per Covered Person each Membership Year.
10. Radiology and Pathology Services: Payment will be made for such services when billed by a Doctor under the
following conditions:
a. For Illness,when provided to a Hospital Inpatient.
b. For Injury,when provided to a Hospital Inpatient or Outpatient or in a Doctor's office.
c. For Medical Emergency,when provided to an Outpatient in the emergency room of a Hospital,but only for
initial care provided within twenty-four(24) hours of the onset of the Medical Emergency.
11. Doctor's Outpatient and Office Visits: Benefits for initial care only will be payable for the Doc;or's Outpatient
services or office visit under the following conditions unless benefits for surgery or other Hospital visits are provided
for the same Doctor for the same date of service.
a. For Injury, when provided in a Hospital Outpatient Department or emergency room within seventy-two
(72) hours of the Injury or in the Doctor's office within fourteen (14) days of the Injury.
b. For Medical Emergency, when performed in the emergency room of a Hospital within twenty-four (24)
hours of the onset of the Medical Emergency.
12. Services in a Free-Standing Ambulatory Facility: Benefits will be-paid for services of a Doctor in a Free-Standing
Ambulatory Facility if such services would be payable in the Inpatient or Outpatient Department of a Hospital.
C. COINSURANCE
When applicable, the amount payable for Services under this Article will be reduced by the Coinsurance percentage
stated in the application.
ARTICLE XIV. PREGNANCY
A. Persons eligible for maternity care shall receive the benefits available under Articles XII and XIII for obstetrics,
abortions, threatened abortions, miscarriages, premature deliveries, ectopic pregnancies, and other conditions or
complications caused by or arising from pregnancy, if normal childbirth would have occurred after two hundred seventy
(270) days of continuous maternity coverage.
B. Additional benefits will be provided for all medically necessary radiology and pathology procedures performed in a
Doctor's office or as an Outpatient in a Hospital.
Group - UCR 17
• � I 1
C. Room and board for a newborn well infant will be provided for as long as the mother is confined in the Hospital
and is eligible for maternity benefits.
D. Under Family Membership at the time of birth, no waiting periods are applicable to newborn children requiring
definitive treatment for medical or surgical reasons at birth.
E. The following are excluded:
1. All services provided by a Doctor to a newborn well infant, except circumcision under a Family Membership;
room and board or nursery care for a newborn well infant when the mother is not eligible for maternity
benefits,or if dependent children coverage is not elected.
2. Coverage for any individual other than a Subscriber or Subscriber's spouse.
F. Prior membership which provided maternity coverage for the Subscriber or spouse in continuous effect to the
Effective Date of this coverage shall be credited toward the waiting period specified herein.
G. Deductibles and Coinsurance as referred to in Articles XII and XIII are applicable.
ARTICLE XV. ORAL SURGERY _
A. Benefits available under Articles XII and XIII will be provided under this Contract for the following services,whether
treatment is provided by a Doctor of Medicine or a Doctor of Dental Surgery or Oral Surgery.
1. Incision of accessory sinuses,salivary glands or ducts.
2. Incision and drainage of cellulitis.
3. Excision of tumors and cysts of the jaws,cheeks,lips,tongue, roof and floor of the mouth.
4. Excision of exostoses of the jaw and hard palate.
5. Surgical procedures required to correct accidental injuries of the jaw (including pathological fractures),cheeks,
lips, tongue, roof and floor of the mouth,when such injuries have occurred while the person is continuously covered
by the Company.
6. Reduction of dislocations of,and excision of,the temporomandibular joints.
7. Bone grafts to the mandible or maxilla.
B. Only the following benefits will be provided under this Contract for or in connection with the removal of impacted
teeth:
1. (Doctor's Office) Payment will be made for surgical services performed in a Doctor's office, as provided in
Article XIII, Paragraph B.1.
2. (Hospital Outpatient) Payment will be made for Hospital services as provided in Article XII, Paragraph B,and
for surgical services performed in a Hospital Outpatient Department as provided in Article XIII, Paragraph B.1.
3. (Hospital Inpatient) Only if the Hospital admission is essential to safeguard the life and health of the Covered
Person because of the existence of a specific nondental organic impairment will payment be made for Hospital services
as described in Article XII, Paragraph A, and for surgical services as described in Article XIII, Paragraph B.1,for
removal of impacted teeth performed as an Inpatient of a Hospital. A Subscriber may apply in writing for a Company
determination before hospitalization by submitting a written statement from the Doctor who will attend the Covered
Person during the hospitalization. After review of the statement, a determination will be made and the Subscriber
advised.
Group— UCR 18
••
C. All other surgical procedures involving the teeth and supporting structures are excluded except that Hospital services
as described in Article XII, Paragraphs A and B, will be provided when the services are performed as an Inpatient or in an
Outpatient Department of a Hospital, if the admission is essential to safeguard the life and health of the Covered Person
because of the existence of a specific nondental organic impairment. A Subscriber may apply in writing for a Company
determination before hospitalization by submitting a written statement from the Doctor who will attend the Covered
Person during the hospitalization. After review of the statement, a determination will be made and the Subscriber advised.
D. All other treatments involving the teeth and supporting structures are excluded, including preparation of the mouth
for dentures, orthodontic care,gingival tissues,or alveolar processes.
E. Deductibles and Coinsurance as referred to in Articles XII and XIII are applicable.
ARTICLE XVI. MENTAL AND NERVOUS ILLNESS, DRUG ADDICTION AND ALCOHOLISM
A. Benefits available under Articles XII and XIII will be provided under this Contract for a Covered Person confined in
a Hospital as an Inpatient,for services provided for acute care of mental and nervous illness,alcoholism,or drug addiction,
or any combination thereof, but not to exceed thirty (30) days per confinement. Successive confinements to a Hospital
shall be deemed to be continuous and to constitute a single Hospital confinement if discharge from and readmission to any
Hospital shall occur within a one-hundred and eighty (180) day period.
B. Additional benefits available under Article XII will be provided under this Contract for acute care and rehabilitative
services provided a Covered Person confined as an Inpatient primarily for alcoholism or drug addiction, in a Hospital or
other facility with which the Company has a specific and separate contract for such acute and rehabilitative-services,subject
to the same limits.as set forth in Paragraph A above.The benefits provided will be governed entirely by the contract which
the Company has with such Hospital or other facility,which contract shall be on file with the Department of Insurance of
the State of Nebraska, but such benefits and covered period shall in no event be less than those described in Paragraph A
above.
C. The Deductible and Coinsurance as referred to in Articles XII and XIII is applicable.
ARTICLE XVII. MAJOR MEDICAL BENEFITS
A. COVERED SERVICES AND SUPPLIES: Benefits will be provided for the following Covered Services and supplies
upon receipt by the Company of a completed Major Medical claim form:
1. Covered hospital charges as provided in Article XII in excess of the limited.number of days stated for Article
XII in the Application.
2. Consultations,surgery,and hospital,office and home visits by Physicians. -
3. Anesthetics and anesthesia service.
4. Oxygen and equipment for its administration and inhalation therapy.
5. Radiology and pathology services for Illness, Injury or Pregnancy.
6. Ambulance service to the nearest facility where the Covered Person may receive appropriate emergency care
for any Illness, Injury or Pregnancy.
7. Physical therapy provided by a qualified licensed professional Physical Therapist under the direct supervision of
a Doctor and as determined to be medically necessary by the Company.
8. Speech therapy when related to a cerebral vascular accident or cerebral tumor, or when the patient has had a
laryngectomy and as determined to be medically necessary by the Company.
9. Initial purchase of orthopedic braces (except shoes or related corrective devices), crutches, and prosthetic
appliances such as artificial limbs and eyes, as prescribed by a Doctor, including subsequent purchases if prior
authorization is given by the Company.
Group— UCR 19
•
•
10. Rental of durable medical equipment when determined to be necessary by the Company and when prescribed
by a Doctor, not to exceed ninety (90) days unless prior approval for an extension is obtained from the Company.
If in the judgment of the Company the purchase of such equipment will be less expensive than rental,the Company
may provide for the initial purchase upon request.
11. Allergy tests and injections of allergy extracts.
12. Routine immunizations.
13. Drugs, intravenous solutions, vaccines, biologicals, and medicines which by law require a Doctor's prescription
and which are commercially available for purchase and are listed in official formularies,except that insulin is covered
for diabetics without a renewal prescription.
14. Services, supplies, or appliances for dental tre tment of natural teeth required as a result of and directly related
to injury occurring while the Covered Person is covered under this Contract and provided within twelve (12) months
of the date of the injury.
15. One set of eyeglasses or contact lenses (and replacements because of a change in prescription of at least one
diopter) required as a result of and directly related to intraocular surgery or ocular injury.
16. Nursingcare bya Registered Nurse R.N. or a Licensed Practical Nurse L.P.N.
9 ( ) (L.P.N.) when the care:
•
a.. Is provided outside a Hospital,and
b. Is ordered by the attending Doctor,and
c. Requires the technical proficiency and scientific skills of a R.N. or L.P.N., subject to the Exclusions
in Section B, Paragraph 8 of this Article.
B. EXCLUSIONS AND LIMITATIONS: In addition to the Exclusions and Limitations stated in Article II of this
Contract,no payment will be made under this Article for:
1. Hospital room and board charges in excess of the daily room allowance stated in the Application.
2. Eye exercises or visual training (orthoptics).
3. Lodging or travel, even though prescribed by a Doctor, for the purpose of obtaining medical treatment,except
as provided in Section A of this Article.
4. Air conditioners,humidifiers,dehumidifiers,purifiers,and any other environmental control equipment.
5. Exercise equipment.
6. Repairs,maintenance or adjustment of durable medical equipment.
7. Dentistry, oral surgery or dental X-rays, except for services covered by Article XV of this Contract or Section
A, Paragraph 14 of this Article.
8. Services for nursing care by a Registered Nurse or a Licensed Practical Nurse for:
a. A private duty nurse for the convenience of the patient or the patient's family who is employed primarily
for bathing,feeding, exercising, homemaking, moving the patient,giving medication, or acting as a companion
or sitter.
b. A private duty nurse who is an immediate relative, i.e., spouse, parent,child,brother or sister,by blood,
marriage,adoption,or member of the household of the Subscriber.
Group— UCR 20
•
•
•
• c. Persons physically able to be transported to receive medical care.
9. Well baby care or routine examinations regardless of age.
•
10. Deductibles or any Coinsurance amounts from any part of this Contract. .
11. Covered charges in excess of the Usual,Customary and Reasonable amount.
12. Marital or similar counseling services or educational services.
13. Social workers and non-licensed psychologists whether or not under the supervision of an attending Physician.
14. Other services or supplies not specifically covered in Paragraph A of this Article.
C. DEDUCTIBLE:
1. A Covered Person's Deductible for a calendar year will be satisfied when expenses for Covered Services and
supplies as stated in Paragraph A, incurred in that calendar year,equal the Major Medical Deductible amount stated in
the Application. The first calendar year begins on the Effective Date of coverage and ends on December 31 of that
same year.
2. When one member of a covered family has satisfied the Major Medical Deductible stated in the Application,
the remaining family members may combine their charges to meet one additional Deductible of the same amount.
after which Major Medical Benefits will be provided to all covered members of the family for the remainder of that
calendar year.
3. If the total covered charges for a calendar year are less than the required Deductible, any covered charges
incurred during October, November, and December of that year may be carried over and applied against the
Deductible for the succeeding calendar year.
D. PERCENTAGE PAYABLE: •
1. After the Deductible has been satisfied, for care and treatment of Nervous and Mental conditions, Drug
Addiction and Alcoholism, in or out of the Hospital, payment will be made for the percentage of covered charges
for these conditions as stated in the Application.
2. For all other conditions, after the Deductible has been satisfied, payment will be made for the percentage of
covered charges stated in the Application.
E. MAXIMUM BENEFITS:
"c• 1. Lifetime maximum benefits payable for each Covered Person for the treatment of Nervous and Mental dis-
3 j orders,Drug Addiction and Alcoholism shall not exceed the amount stated in the Application.
5', 00 2. Lifetime maximum benefits payable for each Covered Person for the treatment of all conditions shall not
exceed the total amount stated in the Application.
3. Lifetime maximums apply to coverage under this Contract and to all benefits paid by the Company under prior
Major Medical coverage.
4. The total lifetime maximum may be restored at any time after a Covered Person has received payments under
this Article in excess of $1,000.00 providing the Company receives satisfactory evidence of insurability and approves
reinstatement of the lifetime maximum in writing.
F. COVERED PERSONS LIMITED LIABILITY (STOP LOSS): When the Deductible and the Coinsurance amounts
under this Article equal the Stop Loss amount stated in the Application, the Company shall pay one-hundred percent
(100%) of the covered services under this Article incurred during the remainder of that calendar year, not to exceed the
lifetime maximum.
Group— UCR 21
, /.
; ,, _ •
G. CLAIMS FILING TIME: Claims must be filed within twelve (12) months from the end of the calendar year in which
the expenses are incurred or as provided in Article III, Paragraph E of this Contract. It is suggested that all claims for one
calendar year be filed with the Company prior to,and separately from,any claim for charges incurred during the succeeding
calendar year.
ARTICLE XVIII. OUTPATIENT AND DOCTOR'S OFFICE RADIOLOGY AND PATHOLOGY SERVICES
A. Benefits will be provided for radiology and pathology services required for the diagnosis or treatment of Illness or
Injury when performed in the Outpatient Department of a Hospital or in a Doctor's office and which are not covered
elsewhere in this Contract.
B. Payments for such services shall not exceed the percentage and maximum stated in the Application.
C. No payments shall be provided under this Article for routine or annual physical examinations,screening examinations,
or services related to dental care.
•
•
•
•
t
i
Group— UCR 22
,
EXHIBIT B-2
-� PPO NEBRASKA
p
PREFERR
ED PROVIDER ORGANIZATION
C/7!I/7iitf:'
C .
MASTER GROUP CONTRACT
FOR EMPLOYERS AND ASSOCIATIONS
PPO Nebraska is a Preferred Provider health benefits plan offered by Blue Cross and Blue Shield of
Nebraska, a mutual insurance company, Licensed by the State of Nebraska.
This Contract provides benefits for specific health services provided to Covered Persons by PPO Nebraska
Physicians, Hospitals and other health care providers. These providers have agreed to furnish services to
Covered Persons in a manner reasonably expected to effectively manage health care costs.
Blue Cross and Blue Shield of Nebraska agrees to make payment for the health services described, defined
and limited herein during the term of this Contract. Coverage will start at 12:01 a.m. on the effective date
stated in the Master Group Application, in consideration of the payment of premiums or charges as provided
in the Master Group Application.
This Contract consists of the Master Group Application, this document and any attachments or endorsements
hereto. Only Blue Cross and Blue Shield of Nebraska can approve a change to this Contract and that
change must be in writing. Any change will affect all Covered Persons and no'agent may change the
Contract in any way.
The Group Applicant, as the agent representing the group health plan, binds all Employees/Members and
their covered dependents who are beneficiaries of such plan, to the terms and conditions of this Contract.
This Contract is made in and governed by the laws of the State of Nebraska. The Employer or Association
making application will be referred to by the personal pronouns "you" or"your," or"Group Applicant." The
Covered Person may also be referred to as "Employee" or as a "Member" of an Association. The defined
terms are capitalized in this Contract.
BLUE CROSS AND BLUE SHIELD OF NEBRASKA
By: ..4.ol4 •a
Richard L. Guffey, Chairman
and Chief Executive Officer
•
TABLE OF CONTENTS
PAGE
Part I. Eligibility, Effective Date of Coverage,Waiting Periods, 1
Evidence of Coverage
Part II. Charges for Coverage; Grace Period 3
Part III. Continuation of Coverage, Conversion Coverage 4
Part IV. Benefits Overview
7
Part V. Benefits For Hospital Services, Except Maternity 11
Part VI. Benefits For Physician's Services, Except Maternity 12
Part VII. Benefits For Maternity 14
Part VIII. Benefits For Mental Illness, Drug Addiction and Alcoholism 15
Part IX. Benefits For Oral Surgery and Dentistry 17
Part X. Benefits For Organ Transplants 18
Part Xl. Benefits for Home Health Aide and Hospice Services 19
Part XII. Benefits For Other Covered Services and Supplies 20
Part XIII. Exclusions and Limitations 25
Part XIV. Procedures for Filing a Claim 28
Part XV. Coordination of Benefits 28
Part XVI. Subrogation 31
Part XVII. Workers'Compensation 31
Part XVIII. Standard Provisions 31
Part XIX. Definitions 32
.L .
9836 Rev.5/1/90
PART I. ELIGIBILITY, EFFECTIVE DATE OF COVERAGE, WAITING PERIODS, EVIDENCE
OF COVERAGE
A. ELIGIBILITY:
1. If you complete the Master Group Application as an employer, each of your employees is eligible to
make application for coverage. Such application, made on our Enrollment Form, may include a request
for coverage of the employee's spouse and other dependents. Such eligibility is, however, subject to a
probationary period and any other conditions stated in the Master Group Application. Dependents must
qualify as Eligible Dependents as defined herein for benefits to be payable.
2. If the Master Group Application is made by an association, every regular member of the association,
their full-time employees and all association employees, are eligible to make application for coverage.
Such application, made on our Enrollment Form, may include a request for coverage of the employee or
the employee and the employee's spouse and other dependents. Such eligibility is, however, subject to a
probationary period and any other conditions stated in the Master Group Application. Dependents must
qualify as Eligible Dependents as defined herein for benefits to be payable.
3. If the Master Group Application is made by some other form of group, eligibility shall be subject to all
conditions, including a probationary period, stated in the Application.
4. Our Enrollment Form is a questionnaire on which the employee provides the information necessary to
determine eligibility for coverage. Our Enrollment Form requires the election of a Membership Unit, and
the identity of dependents.
By Membership Unit, we mean the category of persons to be provided benefits. The following Membership
Units may be selected:
1. Single Membership: This option provides benefits for Covered Services provided to the employee only.
2. Employee-Spouse Membership: This option provides benefits for Covered Services provided to the
employee and his or her spouse.
3. Single Parent Membership: This option provides benefits for Covered Services provided to the
employee and his or her Eligible Dependents, but not to a spouse.
4. Family Membership: This option provides benefits for Covered Services provided to the employee and
his or her Eligible Dependents.
B. EFFECTIVE DATE OF COVERAGE: Subject to any probationary period stated in the Master Group
Application, and the receipt by us of a completed Enrollment Form, coverage for employees, and their Eligible
Dependents, shall be determined by the rules set forth below.
1. For persons eligible on the effective date of this Contract, coverage shall start on that date.
2. Any person who becomes eligible after the effective date of this Contract must submit an Enrollment
Form. This Form must be received by us within thirty-one (31) days of that person becoming eligible.
Coverage shall be effective on the next monthly due date following the person's eligibility date.
3. Persons whose Enrollment Forms are not received by us within thirty-one (31) days of their eligibility
will be required to furnish proof of insurability. If accepted, coverage for such persons will be effective on
the group's monthly due date following approval of their Enrollment Form by us, subject to any Waiting
Periods. At the time of application, the person may request an earlier effective date, provided such date is
after the date the Enrollment Form is submitted and corresponds with a monthly due date.
9836 Rev. 5/1/90 1
4. Coverage under this Contract for any person confined in a Hospital, convalescent hospital, or place of
treatment for mental illness, drug addiction, or alcoholism, on their initial effective date, shall not begin
• unti 12:01 A.M. on the day after dismissal therefrom. If this Contract replaces another Contract with us,
benefits for Covered Services furnished by this Contract shall not begin until the Covered Person is
discharged from the Hospital.
5. If an employee who has a Single Membership wishes to obtain coverage for his or her Eligible
Dependents, that employee must request such change from us in writing. Such request must be made
within thirty-one (31) days of the spouse or other dependents becoming eligible. The employee must
indicate the Membership Unit requested and identify the dependents. If such request is not made within
thirty-one (31) days of the spouse or other dependents becoming eligible, proof of insurability will be
required, and such persons will be subject to Waiting Periods.
If an employee changes from Single Membership to coverage that includes dependents and the
Enrollment Form is received within thirty-one (31) days of the dependent's eligibility, coverage of the
employee's Eligible Dependents shall begin on the group's next monthly due date following the
dependent's eligibility date. At the time the Enrollment Form is submitted, a newly-married employee may
backdate an Employee-Spouse or a Family Membership to the group's last monthly due date before the
marriage.
6. Coverage for Injury or Illness (including the necessary care and treatment of medically diagnosed
congenital defects and birth abnormalities) shall begin at birth for children of an employee with a Family
Membership or Single Parent Membership in effect.
Coverage will also be provided for the child of an employee with an Employee-Spouse Membership for
thirty-one (31) days from the date of birth. To continue such coverage,the employee must request the
Membership be changed to Family Membership or Single Parent Membership within such thirty-one day
period, and pay the additional premium. l
C. WAITING PERIODS:
1. No benefit payment will be made for Covered Services provided for a Pre-existing Condition, congenital
defect or birth abnormality until Blue Cross and Blue Shield of Nebraska coverage has been in effect for at
least 365 continuous days. •
a. Pre-existing Condition is defined as an Illness or Injury for which a physician prescribed
medication or rendered medical treatment or advice within twelve (12) months prior to the effective
date of coverage. A Pre-existing Condition is also defined as an Illness which exhibited symptoms
within twelve (12) months prior to the effective date of coverage or a previous Injury which exhibited
symptoms or complications within twelve (12) months prior to the effective date of coverage, either of
which would lead a prudent person to seek medical treatment or advice.
b. A congenital defect or birth abnormality is defined as a condition existing at or from birth which is
a deviation from the norm, such as clefting, protruding ears, birthmarks, webbed fingers or toes, and
other conditions normally considered congenital defects or birth abnormalities.
2. Benefit payments for Pregnancy, or any complications thereof, shall not be made for services provided
unless normal childbirth either does or would have occurred after 270 days of continuous Blue Cross and
Blue Shield of Nebraska maternity coverage.
D. EVIDENCE OF COVERAGE: When coverage becomes effective for a person in your group,we will provide
that person with a Certificate of Coverage, a Schedule of Benefits, and two PPO Nebraska Identification Cards.
The Certificate of Coverage is a booklet which summarizes the terms of our Contract with you.
9836 Rev. 5 1 90
/ / 2
The Schedule of Benefits is a personalized document generated by us which identifies your coverage option
and the Membership Unit which the employee has selected. By coverage option, we mean the level of benefits
to be provided under this Contract as indicated by you on the Master Group Application. The Schedule of
Benefits provides information as to Deductible Amounts, Coinsurance rates, the Maximum Coinsurance
Liability, and maximum benefits. It also indicates any applicable Waiting Periods.
The Identification Card identifies a person as a member of the PPO Nebraska program. This card must be
presented when services are provided.
PART II. CHARGES FOR COVERAGE; GRACE PERIOD
A. Premiums for coverage are payable monthly in advance, on or before the due date. Payment shall be made
at our home office.
B. The rates in the Master Group Application are used to compute the monthly premium. We may change the
rates: (a) on any due date after the first year if we give you thirty (30) days written notice; or (b) whenever the
Contract terms are changed. It is agreed that the rates may change after thirty (30) days notice if the cost of
providing services and the administration thereof so requires, or if a benefit increase is required by law.
C. Unless otherwise agreed, the monthly charge for your group equals the sum of the applicable premium for
all persons in the group as of the due date.
D. We will allow a thirty-one (31) day grace period after the due date for payment each month. The Contract
remains in force if the payment is received during that(31)day grace period. If we do not receive payment
during the thirty-one (31) day grace period,the Contract is canceled as of midnight of the last day for which
premiums have been paid. No payment shall be made for Covered Services provided after the effective date of
cancellation of this Contract.
E. if payment of a premium for your group is submitted after the'thirty-one (31) day grace period,we may
accept it and issue a conditional receipt, requiring you to submit a new Master Group Application. The
Contract will be reinstated only if we approve the application, or if we do not notify you of disapproval,forty-five
(45) days after the application is received. If the Contract is reinstated,your group will be given a new effective
date. The reinstated Contract covers only loss resulting from Injury which is sustained after the date of
reinstatement and Illness that begins more than ten (10) days after reinstatement. In all other respects, the
Contract rights remain the same. The accepted premium shall be applied to the month of your effective date.
If we do not reinstate your Contract,we will refund the payment which was conditionally received.
F. We may cancel the Contract at any time by notifying you in writing of such cancellation. Such written notice
must be delivered to you or the subgroup at least thirty-one (31) days prior to the effective date of cancellation.
We will not be required to provide notice to individual persons in your group or of any subgroup, if cancellation
occurs, nor will we be required to provide any conversion coverage to persons if we cancel your group
contract
G. We have the right to cancel this Contract pursuant to paragraph F, above, if you enter into a benefit
agreement with any other insurance company or enter into any other benefit financing arrangement, including
becoming self-insured. We will not be required to provide any conversion coverage to persons if we cancel
your group contract pursuant to this paragraph.
H. You may cancel this Contract by written notice to us. Such cancellation shall be effective on the last date
for which premiums have been paid, or a future date specified by you. You will be responsible for payment of
premiums untU any future date specified. We will not be required to notify persons in your group of your
cancellation nor will we be required to provide any conversion coverage to such persons if you cancel your
group. Cancellation shall not affect any claim for services provided before the effective date of cancellation.
I. If you give us proof that a refund of premiums should be made, the refund will be limited to the twelve (12)
month period prior to receipt of this proof.
9836 Rev. 5/1/90 3 1
•
PART III. CONTINUATION OF COVERAGE; CONVERSION COVERAGE
A. CONTINUATION OF COVERAGE
1. Nebraska Continuation Law: Nebraska employers who, based on the number of employees, are not
subject to the federal COBRA continuation law (paragraph 2, below) are subject to the Nebraska
continuation law, Neb. Rev. Stat. Section 44-1640 through 44-1645 (R. S. Supp., 1989). The Nebraska law
provides that an employer must offer the opportunity to continue coverage under this Contract in two
circumstances:
■ Involuntary Termination: If you terminate an employee's employment for reasons other than
misconduct, you must offer that employee the opportunity to continue insurance coverage for up to
six (6) months.
• Death: If one of your covered employees dies, you must offer the opportunity to continue coverage to
a covered spouse or covered dependent children of that employee for a period of one (1) year
following the date of death.
a. If the continuation coverage is elected, it shall continue until the earliest of the following dates:
(1) In the case of a terminated employee, coverage for the employee and his covered
dependents may be continued for up to six (6) months from the date coverage would otherwise
terminate.
(2) In the case of the covered surviving spouse or other covered dependents of a deceased
employee, coverage may be continued for up to one (1) year from the date coverage would
otherwise terminate.
(3)The date the Covered Person becomes eligible for other group health coverage or becomes
eligible for Medicare; and with respect to the surviving spouse, the date such spouse remarries
or becomes eligible fo;Medicare or covered by Medicaid.
(4)The date the conversion option is exercised.
(5)The date on which your Contract with us is terminated. If you terminate your Contract with
us, continuation coverage shall also terminate.We will not provide conversion coverage to any
person who was a Covered Person pursuant to your Contract on the date of termination, nor will
we provide notice to them of the termination of your Contract.
(6)The date on which coverage expires for nonpayment of premium.
b. Payment of premiums for continuation coverage is the responsibility of the terminated employee or
the surviving spouse or dependents of a deceased employee.
c.The employer must send a notice of the right to continuation of coverage to the eligible Covered
Person by certified mail with return receipt requested to the home address of the employee as shown
on your records, no later than ten (10)working days after the termination or death. The notice must
set forth the right to continue coverage, the amount of the monthly premium and the proper
procedure for continuing the coverage.
(1)Terminated employees desiring to continue coverage must return the form and the first
premium by certified mail with return receipt requested to Blue Cross and Blue Shield of
Nebraska, P.O. Box 3248, Omaha, NE, 68180-0001, within ten (10) days after receipt of the
notice.
9836 Rev. 5/1/90 4 ' ,
(2) Covered surviving spouses or dependent children desiring to continue such coverage must
return the election form and the first monthly premium by certified mail with return receipt
requested to Blue Cross and Blue Shield of Nebraska, P.O. Box 3248, Omaha, NE 68180-0001,
within thirty-one (31) days after the date of death of the employee.
d. Premiums for each subsequent month shall be paid by the Covered Person(s) to Blue Cross and
Blue Shield of Nebraska without further notice.
e.The experience from the continuation coverage shall be charged to your group.
2. Federal Continuation Laws: A Nebraska employer may also be subject to Public Law 99-272, the
Consolidated Omnibus Budget Reconciliation Act (COBRA) and subsequent amendments and
regulations. The law applies to group health plans for any calendar year in which the employer employed
twenty (20) or more employees on 50% of its working days during the preceding calendar year. Under
COBRA, a covered employee who would lose coverage due to a reduction in work hours, or the
termination of employment because of voluntary quit, lay-off for economic reasons, or for misconduct
other than gross misconduct, may elect to continue his or her coverage under the group Contract. In
addition, COBRA requires that continuation of group coverage be made available to the covered surviving
spouse and other Eligible Dependents of a covered employee who dies; to a covered employee's spouse
and other Eligible Dependents who would lose coverage because of divorce or legal separation, or
because of the employee's entitlement to Medicare; and,to Eligible Dependent children who would lose
coverage because of loss of dependent status. The above-mentioned circumstances which entitle
persons to elect to continue coverage are known as"qualifying events,"and such persons are known as
'qualified beneficiaries." COBRA coverage may not be conditioned on evidence of insurability and it must
credit qualified beneficiaries with incurred deductibles, coinsurance and maximum limits.
• a. if the continuation coverage is elected, it shall continue until the earliest of the following:
(1)The date of expiration of the period allowed by law, and set forth below, in paragraph b.
(2)The date the person electing coverage becomes entitled to Medicare or covered under
another group health plan which does not exclude or limit any Pre-existing Condition. COBRA
law requires that continuation coverage be available for a Pre-existing Condition that is not
covered under another plan.
(3)The date of expiration of the monthly period for which premiums were paid in the event of a
nonpayment of premium.
(4)The date the group ceases to offer any group health plan to its employees. If you terminate
your Contract with us, continuation coverage will continue with the successor plan of your
group. We will not provide conversion coverage to any person who was a Covered Person
pursuant to your Contract on the date of such termination, nor will we provide notice to them of
the termination of your Contract.
b. Continuation coverage is allowed:
(1) For up to eighteen (18) months after the date of the qualifying event for a covered employee
whose coverage under the Contract would otherwise be terminated because of a reduction in
work hours or the termination of full-time employment of such employee,for the following
reasons: (a) voluntary quit, (b) lay-off for economic reasons, and (c) discharge for misconduct
other than gross misconduct.
(2) For up to twenty-nine (29) months after the date of the qualifying event if the employee is
determined to be disabled under the Social Security Act at the time they become eligible for
COBRA continuation coverage, or within eighteen (18) months of becoming eligible for
continuation coverage. A qualified beneficiary must provide notice to the plan no later than s
(60) days after the date of the Social Security determination.
9836 Rev.5/1/90 5
(3) For up to thirty-six (36) months after the date of the qualifying event for the following groups:
(a) the surviving spouse and other covered dependents of a covered employee,whose
coverage would otherwise be terminated because of the death of such employee, (b) the
covered separated or divorced spouse and children of a current covered employee whose
coverage would otherwise be terminated because of the divorce or legal separation of the
covered employee, and (c) the children of current covered employees whose coverage would
otherwise be terminated because of their loss of dependent status, and (d) the spouse or
dependent children of a covered employee whose coverage would otherwise terminate because
of the employee's entitlement to Medicare. Persons in (b) and (c) must notify you of such event
within sixty(60) days in order to be eligible for such coverage.
c. Payment of premium for continuation coverage is the responsibility of the person electing to
continue coverage.
d. Not later than fourteen (14) days following the date the employer receives notice of the qualifying
event,the employer shall send a notice by first class mail to the eligible person at his or her home
address as shown on the records of the employer. Such notice shall set forth:
(1)The right of the eligible person to elect to continue coverage, and the election form to be
issued in exercising such right.
(2)The amount of each monthly premium to be paid by the terminated employee, or qualified
beneficiary. •
(3) Directions regarding completion and mailing of the election form and amount of each
monthly premium that must be paid.
e. If the person elects to continue such coverage,the election form shall be sent by first class mail to
Blue Cross and Blue Shieid of Nebraska, P.O. Box 3248, Omaha, Nebraska, 68180-0001, or to the
employer, if so directed,within sixty (60) days after the notice is sent or the date the qualified
beneficiary would lose coverage,whichever is later.The first premium must be paid within forty-five
(45) days after the election.
f. Premiums for each subsequent month shall be paid by the Covered Person(s) to Blue Cross and
Blue Shield of Nebraska without further notice.
g.The experience from the continuation coverage shall be charged to your group.
B. CONVERSION COVERAGE
1. ELIGIBILITY: In addition to the right to continuation of coverage provided by State and Federal law,
discussed in the preceding paragraphs,a Covered Person may elect to convert to a coverage plan
separate from the group plan, offered by us. The Covered Person may request conversion coverage
whenever his or her coverage under your group plan is terminated, subject to the following:
a. The Covered Person is no longer eligible for your coverage;
b. The Covered Person becomes eligible for conversion coverage while the group Contract with us is
still in effect;
c. The application for conversion coverage is received by us within thirty-one (31) days of the
termination of the Covered Person's coverage or within thirty-one (31) days of the Eligible
Dependent's ineligibility for group coverage, or within the 180- day-period that ends on the expiration
date following the maximum COBRA coverage period;
d. The payment for the first month's premium must be submitted with the application;
9836 Rev. 5/1/90 6
1 0
•
e. The conversion coverage will be issued under the same type of Membership Unit as is held by the
Covered Person (Single, Employee-Spouse, Single-Parent or Family) without medical underwriting. If
1 appropriate, any Covered Person may apply for a Single Membership conversion if his or her prior
coverage was under any multiple party Membership.
2. CONVERSION CONTRACT
a. Benefits provided by the conversion contract and all other terms and conditions thereof, including
rates shall be determined by us. Such benefits may be different from benefits provided under this
group contract.
b. Any Waiting Period required by the conversion contract shall be reduced by the length of time the
Covered Person converting has been continuously covered by us.
c. If a Covered Person is an Inpatient on the date of change, Hospital benefits for that admission will
be provided under this PPO Nebraska group contract.
PART IV.BENEFITS OVERVIEW
A. PAYMENT FOR SERVICES:
•
1: PPO Nebraska Providers: We have contracted with a panel of Physicians, Hospitals, and other health
care providers,to furnish services to Covered Persons in a manner reasonably expected to effectively
manage health care costs. We call this program PPO Nebraska, and we call these health care providers
PPO Nebraska Physicians, PPO Nebraska Hospitals or PPO Nebraska Providers. The amount of benefit
payment made by us will be different depending on whether or not the service is provided by a PPO
Nebraska Provider. Preferred benefits will be available when the services are provided by a PPO
Nebraska Provider. This means the Deductible Amount and the Coinsurance Amount payable by the
Covered Person will be greater when services are received from a provider who does not contract with
PPO Nebraska. The PPO Nebraska Provider agrees to accept our payment plus payment by the Covered
Person of any Deductible Amount, Coinsurance Amount and any amount for Non-Covered Services, as
payment in full. For benefits to be payable by us, all Covered Services must be Medically Necessary.
a. PPO Nebraska Hospital: If a Covered Person receives care in a PPO Nebraska Hospital because
of Illness, Injury, or Pregnancy, payment will be made to that Hospital for Medically Necessary
Covered Services. We have contracted with the PPO Nebraska Hospital for services at a specific
reimbursement amount based upon the diagnosis and procedures involved. This classification is
called a Diagnostic Related Grouping (DRG). We will pay the amount for the DRG less any
Deductible Amount and Coinsurance.
With certain diagnoses and procedures,we have not computed a DRG. We have contracted with the
PPO Nebraska Hospital for reimbursement of these Covered Services at a specific rate, based upon
billed charges. Benefits will be provided less any Deductible and Coinsurance.
The Covered Person is responsible for the payment of the Deductible Amount, Coinsurance and
charges for any Non-Covered Services. The Coinsurance percentage is applied to the Allowable
Charge for the Covered Service.
b. PPO Nebraska Physician: A PPO Nebraska Physician has entered into an agreement with us that
he or she will accept the lesser of his or her billed charge or the amount set forth in the PPO
Nebraska Physician's Reimbursement Schedule,for Covered Services listed thereon, as payment in
full. If the Covered Service is not listed, the PPO Nebraska Physician has agreed to accept the lesser
of his or her billed charge or the Maximum Benefit Amount as payment in full for Covered Services.
The Covered Person is responsible for payment of any Deductible Amount, Coinsurance and for any
Non-Covered Services. The Coinsurance percentage is applied to Allowable Charges.
9836 Rev. 5/1/90 ;7
c. If a claim is submitted for a Covered Service which is not approved by our Utilization Review
Program, the PPO Nebraska Provider agrees not to charge, collect or seek collection from the
Covered Person, or from us.
EXCEPTION: The PPO Nebraska Provider may collect from the Covered Person, however, for a
specific service, procedure, drug, supply or item of medical equipment where benefits are not
payable pursuant to our Utilization Review Program if, prior to the service being provided, the
Provider has advised the Covered Person in writing, or verbally if documented in the medical record,
that benefits will not be payable by us.
2. Non-PPO Nebraska Providers:
a. Non-PPO Nebraska Hospital: If a Covered Person is confined as an Inpatient in a Non-PPO
Nebraska Hospital because of Illness, Injury or Pregnancy, payment will be made for precertified
Covered Services. The amount of benefit payment will be reduced by the applicable Deductible
Amount and Coinsurance. The Covered Person is responsible for payment of the Deductible
Amount, Coinsurance and charges for any Non-Covered Services.
If the Covered Person fails to obtain precertification of benefits for an Inpatient hospitalization as
required by Part IV.F, or for Inpatient treatment for Mental Illness, drug addiction or alcoholism, as
required by Part VIII,the Allowable Charge considered for benefits for Covered Services will be
reduced by twenty-five percent(25%). The Covered Person.will be responsible for payment of the
amount of the reduction.
b. Non-PPO Nebraska Physician: Benefits for Covered Services shall be paid based on the lesser of
the Physician's billed charge or the Maximum Benefit Amount. The amount of our payment shall be
reduced by the non-preferred Deductible Amount and Coinsurance. The Covered Person is
responsible for the payment of the Deductible Amount, Coinsurance and any amount charged by the )
Physician which is in excess of the Maximum Benefit Amount for the Covered Service. The Covered
Person is also responsible for payment for any Non-Covered Service. The Coinsurance percentage
is applied to Allowable Charges for Covered Services.
If the Covered Person fails to obtain precertification of benefits for Covered Services provided to an
Inpatient at the time of a Non-Emergency Admission as required by Part IV.F, the Allowable Charge
considered for benefits will be reduced by twenty-five percent (25%). The Covered Person will be
responsible for payment of the amount of the reduction.
c. EXCEPTION: If the Covered Person receives Inpatient or Outpatient care at a Non-PPO Nebraska
Hospital or by a Non-PPO Nebraska Physician under the following circumstance, benefits will be paid
for Medically Necessary Covered Services at the PPO Nebraska Provider preferred Coinsurance rate.
The applicable Deductible Amount will be at the PPO Nebraska Provider preferred Deductible rate.
■ In case of a Medical Emergency or accident. A Medical Emergency is the sudden and
unexpected onset of symptoms or the exacerbation of a chronic condition which presents an
acute, severe and immediate life threatening situation or a situation where delay might lead to
irreparable harm.
d. If the Non-PPO Hospital, Non-PPO Physician or other Non-PPO Provider is participating with Blue
Cross and Blue Shield of Nebraska under another Blue Cross and Blue Shield of Nebraska program,
payment will be made pursuant to that particular program. The Hospital will be reimbursed based on
DRG classifications or billed charges, as applicable. The Physician will be reimbursed on the lesser
of the Maximum Benefit Amount or billed charges. These Participating Providers have agreed to
accept our payment, plus the payment by the Covered Person of any Deductible and Coinsurance as
payment in full for Covered Services. The Covered Person is responsible for payment for any No -
Covered Services.
9836 Rev. 5/1/90 8
•
e. The Covered Person may contact us to determine the Maximum Benefit Amount for a specific
procedure code for an Inpatient procedure at the time the Covered Person precertifies that
procedure.
3. Utilization Review: Covered Services provided by Hospital, Physicians and all other health care
Providers are subject to our Utilization Review. Utilization Review is the evaluation by us of the use of a
medical, diagnostic, or surgical procedure or service or the utilization of medical supplies, drugs or
Durable Medical Equipment compared with established criteria in order to determine benefits. Benefits
may be excluded for services, procedures, supplies,drugs or Durable Medical Equipment found by us to
be not Medically Necessary. PPO Nebraska Participating Providers have agreed that the Covered Person
will not be responsible for the charges for services which are determined to be non-payable by our
Utilization Review programs. If benefits for a service by a Non-PPO Nebraska Provider are denied by
Utilization Review and that provider is not participating with Blue Cross and Blue Shield of Nebraska
pursuant to another reimbursement program, the Covered Person will be responsible for payment of the
charge.
4. All payments for Covered Services provided by PPO Nebraska Hospitals, PPO Nebraska Physicians
and other PPO Nebraska Providers, or any provider who is participating with us pursuant to any other
reimbursement program, shall be made directly to such Participating Providers. In all other cases,
payments shall, at our option, be made to the Covered Person, the Covered Person's estate, or the
provider. No assignment,whether made before or after services are provided, of any amount payable
according to this Contract shall be recognized or accepted by, or binding upon us.
5. We reserve the right to contract further with other health care providers and to alter benefit payment
procedures to Participating Providers. Benefit payments rriade directly to a Hospital, a Physician or any
other health care provider under contract with us may be calculated on a charge basis, a per diem basis, a
global fee basis, pursuant to a DRG Program,through a Preferred Provider Organization, or in any other
manner agreed upon between us and the provider. Paymept may be made in this manner if such payment
results in the complete discharge of our liability under this Contract.
6. Other Insurance: If a Covered Person has other health and accident insurance, and the amount of the
billed charges by the provider is in excess of the amount payable under this Contract,the Covered Person
may be responsible for an additional payment pursuant to the Coordination of Benefits provisions in Part
XV.
7. All benefits payable under this Contract shall be paid as soon as possible after the claim has been filed.
8. Large Case Management: We may expand the scope of benefits in an individual case to include
payment for specific services if it appears to us that use of such services will reduce costs or improve the
quality of care. We shall advise the Covered Person and the provider in writing when, and to what extent,
payment for such services will be made. Such expansion of the scope of benefits shall not constitute an
amendment to this Agreement, nor provide a continuing right to receive such services.
B. DEDUCTIBLE
1. A Covered Person's Deductible Amount for a calendar year will be met when Allowable Charges for
9
Covered Services incurred in that calendar year equal the Deductible Amount stated in the Master Group
Application and in the employee's Schedule of Benefits. The first calendar year begins on the effective
date of coverage and ends on December 31 of that same year, unless stated otherwise in the Master
Group Application.
In instances where no PPO Nebraska Provider is available or where there is not a specific mention of the
applicable Deductible Amount,the applicable Deductible will be the non-preferred Deductible Amount.
The Deductible Amount credited to charges by either will be credited and totaled for application to both.
9836 Rev. 5/1/90 9
2.The Deductible Amount must be met each calendar year for each Covered Person on a Single or
Employee-Spouse Membership. Employees with a Family or Single Parent Membership must meet twice
the individual Deductible Amount each calendar year.
3. If the total charges for Covered Services for a calendar year are less than the required Deductible
Amount, such covered charges incurred during October, November, and December of that year may be
carried over and applied against the Deductible Amount for the next calendar year.
C. COINSURANCE: Coinsurance is the percentage of each Allowable Charge which the Covered Person must
pay. The percentage is set forth in the Master Group Application and the employee's Schedule of Benefits.
D. COVERED PERSON'S MAXIMUM COINSURANCE LIABILITY: The Master Group Application for this
Contract contains a Maximum Coinsurance Liability to be paid per year for Covered Services for a Single,
Family, or other Membership Unit. This means that when the Maximum Coinsurance Liability is reached in
each calendar year,we will pay benefits for additional Covered Services without further application of the
Coinsurance, up to the maximum benefits,for the remainder of that calendar year. This computation includes
Covered Services provided by both PPO Nebraska Providers and Non-PPO Nebraska Providers. Coinsurance
Amounts paid by a Single, Family or other Membership Unit for Covered Services provided for Mental Illness,
Drug Addiction and Alcoholism (Part VIII), Organ Transplants (Part XII) and Home Health Aide and Hospice
(Part XI),will not be considered in computing the Maximum Coinsurance Liability.
Computation of the Maximum Coinsurance Liability does not include amounts paid by a Single, Family or other
Membership Unit for services for which this Contract does not provide benefits. Nor does it include such
amount paid if we have determined that the services are not Medically Necessary and,therefore, nonpayable
pursuant to our Utilization Review Program, nor for charges in excess of the Maximum Benefit Amount, nor for
amounts paid as the result of reduction in benefits resulting from a failure to precertify(Part IV.F.).
E. ,
MAXIMUM BENEFITS:
1. The maximum benefits payable for each Covered Person under all provisions of this Contract is one
million dollars ($1,000,000).
2. There are two classifications of benefits within this one million dollar maximum which are subject to
further dollar limitations. These limitations are:
a. The maximum benefits payable for each Covered Person for the treatment of Mental Illness, Drug
Addiction and Alcoholism (Part VIII) is fifty thousand ($50,000) dollars.
b. The maximum benefits payable for each Covered Person for Home Health Aide Services (Part XI)
is ten thousand dollars ($10,000).
3. Benefit maximums apply to coverage under this Contract and to all benefits subject to benefit
maximums paid by us under prior coverage.
F. PRECERTIFICATION AND CONCURRENT REVIEW:
1. PRECERTIFICATION: This Contract requires precertification of benefits in certain circumstances.
Precertification authorizes payment of benefits for an Inpatient admission subject to the other terms of the
Contract, including but not limited,to determination of eligibility and Pre-existing Conditions.
Precertification is not a guarantee of payment. Benefits for all Covered Services provided for a non-
emergency Hospital Inpatient Admission by a Non-PPO Nebraska Physician or at a Non-PPO Nebraska
Hospital must be precertified. When a Covered Person is treated by a PPO Nebraska Physician and is
hospitalized in a PPO Nebraska Hospital,there is no need for precertification, however, benefits for
Covered Services for all admissions for treatment of Mental Illness, drug addiction or alcoholism must be
approved prior to admission. It is the Covered Person's responsibility to see that we are notified when
precertification is required. Actual notification to us may be made by the treating Physician, the Hospital
or Treatment Center, or by the Covered Person or someone acting on the Covered Person's behalf.
9836 Rev.5/1/90 10
When precertification is requested, we will advise the Physician,the Hospital or Treatment Center, the
Covered Person or someone acting on the Covered Person's behalf, in writing, of the following:
,l
a. Whether benefits will be certified for Inpatient care; and
b. The number of Medically Necessary days which will be considered for determining benefit
payment for an approved Inpatient stay.
Such authorization shall be valid if the Covered Service is provided within sixty (60) days of the
authorization. If the anticipated admission date changes, we should be notified. If a Covered Person does
not obtain precertification, or if precertification is denied, and the Covered Person is admitted to the
Hospital or Treatment Center, the Allowable Charges considered for benefits under this Contract for all
Covered Services associated with this admission will be reduced by twenty-five percent (25%).
2. CONCURRENT REVIEW: Where benefits have been precertified for a period of Inpatient
hospitalization, payment will be made for Covered Services pursuant to this Contract. If additional days
beyond the number of days originally precertified for benefit consideration are needed,these days must
also be precertified in advance. It is the Covered Person's responsibility that we be notified of the need for
additional Inpatient days. Notification to us may be made by the treating Physician, the Hospital or
Treatment Center, the Covered Person, or someone acting on the Covered Person's behalf. We will
advise the treating Physician, Hospital or Treatment Center, and the Covered Person if additional Inpatient
days will be considered for benefit payment, in writing. Allowable Charges considered for benefits for all
Covered Services provided during any period of a hospitalization which extends beyond the length of stay
precertified by us will be reduced by twenty-five percent (25%).
3. If the benefit amount paid by us is reduced as a result of this Part IV.F,the benefit reduction becomes
l an additional amount which must be paid by the Covered Person. This amount paid by the Covered
J .Person will not be considered in computing the Maximum Coinsurance Liability, as defined in Part IV,D.
PART V. BENEFITS FOR HOSPITAL SERVICES, EXCEPT MATERNITY
A. OVERVIEW: Admission to a Hospital and all services must be ordered by a Physician. The following
Hospital Services are Covered Services under this Contract. This means that, subject to the Exclusions and
Limitations set forth in Part XI, including determinations made by our Utilization Review Program, benefits will
be provided for these services when provided to a Covered Person.
B. COVERED HOSPITAL INPATIENT SERVICES:
1. Hospital Room: Benefits will be provided for Hospital room and board. We will consider any special
diet, and all nursing services included in the Hospital room charge. Benefits will be based upon the
amount charged for a semiprivate room. If an intensive care unit, cardiac care or similar type of room is
Medically Necessary, benefits will be based upon the reasonable charge for such room. When a Covered
Person is confined to a private room, benefits shall be based upon the average charge for 2-bed
accommodations in that Hospital, unless the patient is confined to a private (isolation) room to prevent
contagion and we determine that isolation was ordered, utilized and was Medically Necessary.
2. Use of operating, cystoscopic, cast, recovery and other surgical treatment rooms and equipment.
3. Anesthetics and their administration when performed by a Hospital employee.
4. Respiratory care including oxygen,administered by a certified respiratory therapist who is a Hospital
employee.
5. Drugs, intravenous solutions,vaccines, biologicals, and medicines which are prescribed for and
administered to the Covered Person while hospitalized.
6. Administration of intravenous solutions, blood, blood plasma, blood derivatives, or blood fractiona e. :,
9836 Rev. 5/1/90 1`1 CO
Supplies,'
7. materials and equipment,
qu pment, including dressings, splints and plaster casts, except`take-home'
supplies and convenience items.
8. Radiology and pathology services when billed by the Hospital.
9. Physical therapy when provided by a licensed physical therapist, or other qualified person, as an
employee of the Hospital.
10. Occupational therapy consisting of range of motion exercises, strengthening exercises and prosthetic
training to achieve pain relief, restoration of function, the prevention of disability or further deterioration for
the following conditions:
Hand and upper extremity injuries;
Joint dysfunction resulting from arthritis;
Post mastectomy;
Burn care;
Amputation.
Such services must be provided by a licensed occupational therapist or licensed occupational therapist
assistant,who is an employee of the Hospital.
Benefits shall not be provided for any other occupational therapy services including, but not limited to:
•
Training to compensate for perceptual impairment; - )
Teaching and practicing the activities of daily living;
Developing prevocational capacity.
11. Speech therapy when provided by a'licensed speech-language pathologist or person practicing under
the direct supervision of a licensed speech-language pathologist.
C. COVERED HOSPITAL OUTPATIENT SERVICES AND FREESTANDING AMBULATORY SERVICES
1. Payment will be.made for Outpatient Hospital services or services provided by a Freestanding
Ambulatory Facility as identified in Section B, 2 through 8, above. For such services to be payable,they
must be, in our opinion, Medically Necessary for the specific conditions being treated.
2. Payment will be made for a observation room or postoperative holding room charge, not to exceed
the average cost of a semi-private room in Nebraska, for a period of one day. If an intensive care unit,
cardiac care or similar type of room Medically Necessary, benefits will be based upon the reasonable
charge for such room, for a period of one day.
PART VI.BENEFITS FOR PHYSICIAN'S SERVICES, EXCEPT MATERNITY
A. OVERVIEW: The following Physician's services are Covered Services under this Contract This means that
subject to the Exclusions and Limitations set forth in Part XIII, including determinations made by our Utilization
Review Program, benefits will be paid for these services when provided to a Covered Person.
B. COVERED PHYSICIAN SERVICES:
1. Surgery: Operative invasive procedures and the treatment of fractures and dislocations provided by \....._r.
the Physician in charge of the case, or by a certified physician's assistant within the scope of his or her
1
9836 Rev.5/1/90 - 12 -
! Y•
practice. The amount payable for a surgical procedure shall include the normal preoperative and
postoperative care of a Hospital Inpatient or Outpatient, or in a Freestanding Ambulatory Facility.
a. When the normal preoperative or postoperative care of the Hospital Inpatient is performed by a
Physician other than the person actually performing the surgical procedure, the surgeon's benefit will
be limited to 60% of the amount payable for the procedure. The Physician providing the normal
preoperative or post operative care shall be reimbursed up to 40%of the amount payable for the
procedure.
b. When multiple or bilateral surgical procedures are performed which add significant time or
complexity at the same operative session, benefits shall be paid for the primary procedure as
. determined by us. For any secondary procedure, benefits shall be provided at 75% of the amount
payable had the procedure been primary. For any additional procedure, benefits shall be provided at
50% of the amount payable had the procedure been primary. When a surgical procedure is
performed in two or more steps or stages, payment will be limited to the amount provided for a single
procedure.
2. Surgical Assistance: Payment will be made for surgical assistance by a Physician or certified physician
assistant who actively assists the operating physician. The amount payable will not exceed 20% of the
PPO Nebraska Physician's Reimbursement Schedule amount or the Maximum Benefit Amount for the
surgery,whichever is applicable. Surgical procedures.for which benefits for a surgical assistant are
provided are those specifically identified by us. Such information may be obtained from us prior to
surgery.
3. Anesthesia Services: The administration of an anesthetic by a Physician or a certified registered nurse
anesthetist. Anesthesia services shall include the usual preoperative and postoperative visits and the
administration of fluids or blood incident to the anesthesia or surgery, but shall not include administration
of anesthesia by the attending or assisting surgeon (except spinal, saddle or caudal blocks) nor local
infiltrations by whomsoever administered.
4. Nonsurgical Inpatient Hospital Visits: Nonsurgical Inpatient care or treatment of a condition for which
surgical care is not required.
5. Concurrent Inpatient Hospital Visits: An Inpatient Hospital visit provided by two or more Physicians on
the same day if, in our opinion, the services are:
a. For unrelated nonsurgical medical diagnoses which require the services and skills of two or more
Physicians with unrelated specialties; or
b. Necessary because of medical complications requiring nonsurgical care not related to surgery
and not a part of the usual, necessary and related preoperative and postoperative care and requiring
supplemental skills not possessed by the attending surgeon or his or her assistants.
6. Inpatient Consultation Service: When a Covered Person is an Inpatient, payment will be made for one
Physician consultation per specialty when the following requirements are met:
a. Requested by the attending Physician; and
b. Required by the Covered Person's Illness or Injury and beyond the special knowledge or practice
specialty of the attending or other consulting Physician; and
c. Consultation includes a physical examination of the Covered Person by the consulting Physician;
and
d. A written report from the consulting Physician is included in the Covered.Person's Hospital chart.
9836 Rev. 5/1/90 1.3�
7. Intensive Medical Service: Unusual, repeated and prolonged attendance at the Covered Person's
bedside when required by the Illness or Injury.
8. Radiation Therapy.
9. Tissue Examinations: Tissue examinations in connection with surgical procedures, whether performed
in a Hospital Inpatient or Outpatient facility, Freestanding Ambulatory Facility, or in the Physician's office.
10. Pap Smears.
11. Radiology and Pathology Services.
12. Physician Home,Office and Outpatient Visits: Payment will be made for such services. Included
within this service is care associated with renal dialysis, not billed pursuant to another procedure.
13. Psychotherapy or psychological counseling services provided by a Physician or certified clinical
psychologist or by a registered nurse, certified master social worker or licensed psychologist working
under the direct supervision of a Physician or certified clinical psychologist.
14. Biofeedback procedures, up to a limit of twelve (12) per patient, per calendar year.
PART VII. BENEFITS FOR MATERNITY
A. Benefits shall be paid for Medically Necessary Hospital and Physician Covered Services pursuant to Parts V
and VI of this Contract, when such services are provided to a Covered Person, if eligible for maternity benefits,
as the result of a Pregnancy. Payment for prenatal and postnatal care is included in the payment for the
delivery.
B. Additional benefits will be provided for all Medically Necessary radiology and pathology
porformed in a Physician's office or the Outpatient department of a Hospital. pro procedures
C. Room and board for a newborn infant will be provided for as long as the mother is confined in Hospital and
eligible for maternity benefits.
D. Benefits for Medically Necessary Covered Services provided for a Maternity Admission must be precertified
by us if such admission is to a Non-PPO Nebraska Hospital, or if delivery is by a Non-PPO Nebraska Physician.
It is the Covered Person's responsibility that we be notified of the Maternity Admission. Notification to us may
be made by the Physician, the Hospital,the Covered Person, or someone acting on behalf of the Covered
Person. Notification may be made at any time prior to admission or within twenty-four(24) hours after
admission. The Covered Person will be notified that benefits will be provided for a specific number of Medically
Necessary Inpatient days. If the Covered Person wishes additional Inpatient days for either the mother or the
newborn child, or both, a request for the additional benefits must also be made to us. Such request may also
be made by the Physician, the Hospital, the Covered Person, or someone acting on behalf of the Covered
Person. If additional days are precertified for either the mother or the newborn child, we will notify the treating
Physician,the Hospital and the Covered Person that benefits will be provided for Covered Services.
If the Covered Person does not request precertification, Allowable Charges considered for benefits by this
Contract for all Covered Services provided during the Maternity Admission will be reduced by twenty-five
percent (25%). Allowable Charges considered for benefits for all Covered Services provided during any period
of a hospitalization which extends beyond the length of stay precertified by us will be reduced by twenty-five
percent (25%). The Covered Person will be responsible for payment of the amount of the reduction.
E. Under a Family or Single Parent Membership, at the time of birth, no Waiting Periods are applicable to
newborn children requiring definitive medical or surgical treatment. i
Such definitive medical or surgical treatment shall also be provided for the newborn child of a person with ara.A -
Employee-Spouse Membership for thirty-one (31) days from the date of birth. To continue such coverage,the
9836 Rev.5/1/90 14
•
employee must request that the Membership Unit be changed to a Family or Single-Parent Membership within
such thirty-one day period by filing an Enrollment Form with us and paying the additional premium.
F. The following are excluded:
1. All Physician servics provided to a newborn well infant, except circumcision;
2. Room and board or nursery care for a newborn well infant when the mother is not eligible for maternity
benefits.
G. Benefit payment is contingent, however, upon normal childbirth occurring, or being scheduled to occur,
after 270 days of continuous Blue Cross and Blue Shield of Nebraska maternity coverage. We will consider any
period during which maternity coverage was in continuous effect with us, prior to the effective date of this
Contract in computing the 270-day period.
H. Benefits will not be provided pursuant to this Part VII for post partum depression, psychosis or any other
Mental Illness. Benefits for such conditions are provided by Part VIII, and subject to the limitations therein.
PART VIII. BENEFITS FOR MENTAL ILLNESS, DRUG ADDICTION AND ALCOHOLISM
Benefits will be provided to a Covered Person for Covered Services provided for treatment of Mental Illness,
drug addiction or alcoholism, or any combination thereof, as follows:
A. Covered Services: Covered Services for the acute care of Mental Illness, drug addiction or alcoholism, or
any combination thereof, shall be those Hospital services listed in Part V, and those Physician services listed in
Part VI. Benefits will not be provided for treatment modalities which are identified as Non-Covered Services in
Part XIII of this Contract.
•
B. inpatient and Day Care: Benefits will be provided for Inpatient treatment for up to thirty(30) days per
calendar year. Al! Inpatient services for Mental Illness, drug addiction or alcoholism must be precertified by us.
A person shall be considered an Inpatient for this Part VIII if he or she is confined to a Hospital or to an
Alcoholism or Drug Treatment Center. A person is considered confined if he or she spends less than six(6)
hours daily outside of such facility at work, or school, or otherwise independent of direct facility supervision.
Such benefits will not be provided.to a person who is not confined as an Inpatient but is receiving care at a Day
Care or Outpatient facility.
1. Payment for Inpatient Services:
a. PPO Nebraska Providers: We have contracted with the PPO Nebraska Hospital or Treatment
Center for reimbursement of Covered Services at a specific rate, based upon billed charges. If a
Covered Person is confined as an Inpatient in a PPO Nebraska Hospital or Alcoholism or Drug
Treatment Center, payment will be made to that Hospital or Treatment Center for Covered Services.
A PPO Nebraska Physician has entered into an agreement with us that he or she will accept the
lesser of his or her billed charges or an amount set forth in the PPO Nebraska Physician's
Reimbursement Schedule, for Covered Services listed thereon, as payment in full. If the Covered
Service is not listed,the PPO Nebraska Physician has agreed to accept the lesser of his or her billed
charge or the Maximum Benefit Amount as payment in full for Covered Services.
PPO Nebraska Providers agree to accept our payment plus the payment by the Covered Person of
any Deductible, Coinsurance, charges for Non-Covered Services and charges for Inpatient care in
excess of thirty (30) days per calendar year, as payment in full.
If a claim is submitted on a service which is not approved by our Utilization Review Program,the PPO
Nebraska Provider agrees that it will not charge, collect or seek collection from the Covered Person
or from us.
9836 Rev. 5/1/90 15
•
EXCEPTION: PPO Nebraska Providers may collect from the Covered Person, however, for a
specific service, procedure, drug, or supply where benefits are not payable pursuant to our Utilization
Review Program if prior to the service being provided,the Provider has advised the Covered Person
in writing, or verbally if documented in the medical record, that the benefits will not be payable by us.
b. Non-PPO Nebraska Providers: If a Covered Person is confined as an Inpatient in a Non-PPO
Nebraska Hospital or Alcoholism and Drug Treatment Center, payment will be made for Medically
Necessary Covered Services based on the reasonable charge for such services. If the Covered
Person receives Covered Services from a Non-PPO Nebraska Physician or other provider, benefits
will be paid at the lower of billed charges or Maximum Benefit Amount.
The Covered Person is responsible for the payment of the Deductible, the Coinsurance, charges for
Non-Covered services, and for charges for services in excess of thirty (30) days per calendar year. In
addition, the Covered Person is responsible for the payment of any amount charged by the Provider
in excess of the Maximum Benefit Amount. The Coinsurance percentage is applied to the Allowable
Charges, and the Coinsurance and Deductible amounts will be the Non-PPO Nebraska Coinsurance
and Deductible Amounts.
EXCEPTION: If the Covered Person receives Inpatient care at a Non-PPO Nebraska Hospital or
Treatment Center, or receives care from a Non-PPO Nebraska Physician under the following
circumstance,benefits will be paid for Medically Necessary Covered Services at the PPO Nebraska
preferred Coinsurance and Deductible rate:
(1) In case of a Medical Emergency. A Medical Emergency is the sudden and unexpected
onset of symptoms or the exacerbation of a chronic condition which presents an acute, severe
and immediate life threatening situation or a situation where delay might lead to irreparable
harm. ).
If the Novi-PPO Providers are participating with Blue Cross and Blue Shield of Nebraska under
another Blue Cross and Blue Shield of Nebraska program, payment will be made for Covered
Services pursuant to that program. These Participating Providers have agreed to accept our
payment plus payment by the Covered Person of any Coinsurance, Deductible and charges for any
Non-Covered Services as payment in full.
C. Payment for Outpatient Services:
1. PPO Nebraska Provider: A PPO Nebraska Provider has entered into an agreement with us that he or
she will accept the lower of his or her billed charge or an amount set forth in the PPO Nebraska
Physician's Reimbursement Schedule for Medically Necessary Outpatient Covered Services listed
thereon,as payment in full. If the Covered Service is not listed,the PPO Nebraska Provider has agreed to
accept the lesser of his or her billed charge or the Maximum Benefit Amount as payment in full for
Covered Services. Benefits will be paid by us for such Covered Services at 70% of the Allowable Charge.
The Covered Person is responsible for payment of the Deductible, the 30% Coinsurance amount and
charges for Non-Covered Services.
If a claim is submitted which is not approved by our Utilization Review Program, the PPO Nebraska
Provider agrees that he or she will not charge, collect or seek collection from the Covered Person, or
anyone responsible for the Covered Person, or from us.
EXCEPTION: The PPO Nebraska Provider may collect from the Covered Person, however, for a specific
service, procedure, drug, supply or item of medical equipment where benefits are not payable pursuant to
our Utilization Review Program if prior to the service being provided,that Provider has advised the
Covered Person in writing, or verbally if documented in the medical record, that the benefits will not be
payable by us and the Covered Person has agreed to be responsible for reimbursement to the Physician.
9836 Rev. 5/1/90
16
2. Non-PPO Nebraska Provider. If a Covered Person receives Medically Necessary Covered Services
from a Non-PPO Nebraska Provider, benefit payment will be based on the lesser of the Provider's billed
charges or Maximum Benefit Amount. Benefits will be paid by us for such Covered Services at fifty
percent (50%) of the Allowable Charge. The Covered Person is responsible for payment of the Deductible,
the 50% Coinsurance amount, any amount in excess of the Maximum Benefit Amount, and any charges
for Non-Covered Services.
D. THIS CONTRACT DOES NOT PROVIDE BASIC COVERAGE FOR ALCOHOUSM,AS DEFINED IN
SECTIONS 44-769 TO 44-781, R.R.S. 1943. SUCH COVERAGE FOR THE TREATMENT OF ALCOHOUSM IS
AVAILABLE IF YOU SPECIFICALLY REQUEST IT,AND THEN ONLY UPON SUCH TERMS AND CONDITIONS
AS WE CAN AGREE WITH YOU TO PROVIDE.
PART IX. BENEFITS FOR ORAL SURGERY AND DENTISTRY
A. Benefits will be provided pursuant to Part IV for the following Covered Services, if performed by a Physician
or dentist:
1. The removal of impacted teeth in a Provider's office, Freestanding Ambulatory Facility or Hospital
Outpatient department;
2. Incision and drainage of cellulitis;
3. Excision of exostoses,tumors and cysts,whether or not related to the temporomandibular joint of the
jaw;
•
4. Invasive surgical procedures of the jaw or the temporomandibular joint.of the jaw;
5. Bone grafts to the jaw except those done to prepare the mouth for dentures, or for periodontal
purposes;
6. Reduction of a complete dislocation or fracture of the temporomandibular joint of the jaw required as a
direct result of an accidental Injury occurring while the patient was a Covered Person under this Contract.
Benefits for such services are limited, however,to services provided within twelve (12) months of the date
of Injury. Benefits shall not be provided for such services when the dislocation or fracture occurs at the
result of eating, biting or chewing;
7. Services, supplies or appliances for dental treatment of natural teeth required as the direct result of an
accidental injury occurring while this Contract is in effect. Benefits for such services are limited, however,
to services provided within twelve (1.2) months of the date of Injury, or unless otherwise preauthorized by
us. Benefits shall not be provided for such services when the Injury occurs as the result of eating, biting or
chewing;
8. Osteotomies performed for a gross congenital abnormality of the jaw which cannot be treated by
orthodontic appliances and orthodontic treatment; and
9. Hospiital Inpatient charges related to Covered Services for oral surgery and dentistry, if Medically
Necessary as determined by us. In addition, benefits for Hospital Inpatient charges will be provided if the
Hospital admission is essential to safeguard the health of the patient because of the existence of a specific
non-dental physical organic impairment. Prior to hospitalization, a Covered Person may request a
determination of benefits by submitting to us a written statement from the Physician or dentist.
B. EXCLUSIONS: No payments shall be made under this Part IX, or under any other part of this Contract,
except for services expressly described in paragraph A, above,for:
1. Care in connection with the treatment, filling, removal, repositioning or replacement of teeth;
2. Root canal therapy or care;
9836 Rev. 5/1/90 17 �'
•
3. Preparation of the mouth for dentures;
4. Treatment of the dental occlusion or temporomandibular joint of the jaw by any means or for any
reason, except as described in Paragraph A4 and A6 of this Part IX. No benefits will be provided for any
other treatment of Temporomandibular Joint (TMJ) Syndrome.
5. All other procedures involving the teeth or structures directly related to or supporting the teeth,
including:
a the gums;
b. the alveolar processes;and
c. temporomandibular joint of the jaw.
PART X. BENEFITS FOR ORGAN TRANSPLANTS
A BENEFITS FOR THE COVERED PERSON WHO IS A RECIPIENT OR DONOR:
1. Benefits will be provided for the following Medically Necessary Covered Services:
a. Medical, and surgical services, pursuant to Part VI;
b. Hospital services pursuant to PartV; ,
c. Durable Medical Equipment pursuant to Part XI;
d. Prescription medication pursuant to Part XI;
directly related to, or resulting from, a transplant of the following body organs:
(1) Liver;
(2) Heart;
(3) Heart-Lung; or
(4) Pancreas;
where the recipient or donor of the organ is a Covered Person.
2. Benefits will be provided for transportation to and from the site of the transplant procedure for the
Covered Person. Such benefits will be limited to the reasonable cost of land or commercial air
transportation.
3.Additional Benefits-Donation of Organs: Benefits up to$10,000 will be provided for Medically
Necessary Covered Services directly related to, or resulting from, the above transplant procedures for the
following:
a Hospital, medical, surgical or other Covered Services provided to Non-Covered Person donors;
b. Services provided for the evaluation of organs including, but not limited to, the determination of
tissue matches;
c. Services provided for the removal of organs from nonliving donors;
I
9836 Rev.5/1/90 18
d. Services provided for the transportation and storage of donated organs.
Benefits provided to Non-Covered persons shall be secondary to benefits provided to those persons
pursuant to their own hospital, medical, surgical, or major medical coverage.
4. Benefits for kidney transplant services will be provided pursuant to Medicare guidelines.
B. EXCLUSIONS AND LIMITATIONS: Benefits provided by this Part X will also be subject to the specific
limitations set forth herein.
•
1.Transplant Benefit Period Limitation: The Transplant Benefit Period is defined as the period from five
days immediately prior to, and one year immediately following,the transplant procedure (370 days).
Benefits will be provided for only one transplant procedure during the Transplant Benefit Period.
2. Purchased Organs: Benefits will not be provided for the purchase of human organs which are sold
rather than donated to the recipient.
3. Non-Human or Artificial/Mechanical Organs: Benefits will'not be provided for transplantation of any
nonhuman organ to a human recipient, or the implantation of an artificial/mechanical organ into a human
recipient. This provision does hot apply to the implantation of pacemakers.
C. PREAUTHORIZATION: All benefit payments for organ transplant procedures must be preauthorized by us
in writing. Preauthorization shall be initiated by the Covered Person, in writing, to us requesting that benefits be
paid for an organ transplant procedure. This request must be rrtade before the procedure is performed, and be
accompanied by documentation from the Covered Person's Physician demonstrating the Medical Necessity of
the proposed transplant. This request should also indicate at what hospital the transplant procedure will be
performed. This written request should be directed to:
Medical Support Department
Blue Cross and Blue Shield of Nebraska
P.O. Box 3248
Omaha, Nebraska 68180-0001
We will respond in writing advising the Covered Person as to whether benefits are available.
BENEFITS WILL BE REDUCED BY 20% FOR THE ORGAN TRANSPLANT PROCEDURES USTED IN THIS
PART X IF SUCH PROCEDURES ARE NOT PREAUTHORIZED.
PART XI. BENEFITS FOR HOME HEALTH AIDE AND HOSPICE SERVICES
A. HOME HEALTH AIDE: Benefits will be paid pursuant to Part IV for Medically Necessary Home Health Aide
Services provided in lieu of hospitalization by a licensed or Medicare-certified Home Health Agency.
1. Home Health Aide Services shall mean personal care services provided to the Covered Person that
relate to the treatment of his or her medical condition. Such services include, but are not limited to
bathing,feeding and performing household cleaning duties directly related to the Covered Person. Such
services must be ordered by a Physician,and performed under the supervision of a registered nurse.
B. HOSPICE SERVICES: Benefits will be paid for Medically Necessary Hospice Services provided primarily in
the Covered Person's home by a Medicare-certified or Joint Commission on Accreditation of Health Care
Organization accredited Hospice. A Hospice is a program of care provided for persons diagnosed as
terminally ill, and their families. Benefits are subject to the following requirements:
1. The Covered Person must have a life expectancy of six (6) months or less;
2. The Hospice Services must be ordered by a Physician;
9836 Rev.5/1/90 19
•
3. Those services provided must be appropriate for palliative support, treatment or management of
terminal Illness.
Hospice Services include the following:
1. Home Health Aide Services;
2. Respite Care: Short-term Inpatient care which is necessary for the Covered Person in order to give
temporary relief to the person who regularly assists with the care at home. Respite Care must be provided
in a skilled or intermediate"care nursing facility that is affiliated with the Hospice that is providing services
to the Covered Person. Respite Care in a skilled or intermediate care nursing facility need not meet the
Company's normal Medical Necessity criteria ordinarily applied to Inpatient admissions;
3. Medical Social Services: Services provided by a medical social worker employed by the Hospice,
directly related to the Covered Person's medical condition;
4. Crisis Care: Extended skilled nursing care provided at the home of the Covered Person for up to
twenty-four(24) hours per day. Benefits will be available for such care if provided in lieu of a Medically
Necessary Inpatient hospitalization;
5. Bereavement Counseling: Up to five (5) one hour counseling sessions provided to a Covered Person
who is a family member of the deceased Covered Person who was the recipient of Hospice Services,
provided within six (6) months of the death.
C. EXCLUSIONS AND LIMITATIONS: Benefits payable for Home Health Aide Services and Hospice Services,
are subject to the maximum benefits stated for the Contract. Benefits payable for Home Health Aide Services
and Hospice Services are subject to the following additional limitations:
1. Home Health Aide Services may not exceed maximum benefits of$10,000;
2. Hospice Respite Care Services may not exceed a maximum of ten (10) days;
3. Hospice Medical Social Services may not exceed a maximum of eight (8) one-hour sessions;
•
4. Hospice Crisis Care Services may not exceed a maximum of fifteen (15) days;
In addition to the Contract Exclusions found in Part XIII, benefits will not be provided for:
1. Services performed by volunteers;
2. Pastoral services, or legal or financial counseling services;
3. Services which are primarily for the convenience of the patient, or a person other than the patient;
4. Home delivered meals;
5. Any maintenance therapy for non-hospice related Home Health Aide Services, which is therapy not
designed to improve the Covered Person's condition; or
6. Services for Mental Illness or psychiatric care.
PART XII. BENEFITS FOR OTHER COVERED SERVICES AND SUPPLIES
A. COVERED SERVICES AND SUPPLIES: The benefits paid pursuant to this Part XII will be subject to the /
appropriate Deductible based on the Provider's PPO status. Benefits will be paid at 80% (unless otherwise "
stated in the Master Group Application) of billed charges for the following Medically Necessary Covered 1,
Services and supplies when not covered elsewhere under this Contract:
9836 Rev.5/1/90 20
1. Oxygen and equipment for its administration and inhalation therapy.
2. Ambulance service to the nearest facility where the Covered Person may receive appropriate care for a
Medical Emergency.
3. Up to sixty (60) Outpatient physical therapy sessions per year provided by a licensed physical therapist
or other qualified person under the direct supervision of a Physician. A session is defined as a visit to the
physical therapist not to exceed four(4) hours per day.
4. Up to sixty (60) Outpatient occupational therapy sessions per year consisting of range of motion
exercises, strengthening exercises, and prosthetic training to achieve pain relief, restoration of function,
the prevention of disability or further deterioration for the following conditions: •
Hand and upper extremity injuries;
•
Joint dysfunction resulting from arthritis; •
Post mastectomy;
Burn care;
Amputation.
Such services must be provided by a licensed occupational therapist or licensed occupational therapist
assistant, under the direct supervision of a Physician. A session is defined as a visit to the occupational
therapist not to exceed four (4) hours per day.
Benefits shall not be provided for any other occupational therapy services including, hut not limited to:
Perceptual training to compensate for perceptual impairment; .
Teaching and practicing the activities of daily living;
Developing prevocational capacity.
5. Speech therapy when related to a cerebral vascular accident, closed head-trauma, a cerebral tumor,
external trauma, or when the patient has had a laryngectomy. Such services must be provided by a
licensed speech-language pathologist or person practicing under the direct supervision of a licensed
speech-language pathologist.
6. Rental or initial purchase,whichever is least costly, of certain items of Durable Medical Equipment
when prescribed by a Physician. We may preauthorize a second or subsequent purchase of an item of
Durable Medical Equipment, if such purchase is made necessary by a significant change in the Covered
Person's condition or in the case of the growth of a child who is an Eligible Dependent. Benefits will not
be provided for the repair, maintenance or adjustment of Durable Medical Equipment or for sales tax on
the purchase thereof. Benefits will not be provided for Durable Medical Equipment rented, purchased
from or used while confined in a Hospital, a skilled nursing facility, an intermediate care facility, or a
nursing home or any other licensed residential facility if such equipment is usually supplied by such
facility.
7. Any medicinal preparation which:
a. by law requires a Physician's or dentist's prescription or order and must bear the legend: Caution-
-Federal law prohibits dispensing without a prescription;
b. is dispensed by a registered pharmacist on the prescription or order of a Physician or dentist; and �}
9836 Rev. 5/1/90 21
c. may lawfully be dispensed by a registered pharmacist in the State of Nebraska.
8. Insulin.
9. Routine immunizations.
10. Allergy tests and injections of allergy extracts.
11. One set of eyeglasses or contact lenses or replacement of one set of eyeglasses or contact lenses,
because of a change in prescription of at least one diopter as a direct result of intraocular surgery or
ocular Injury, if ordered by a Physician.
12. Nursing care in the Covered Person's home,which requires the skill, proficiency and training of a
registered nurse (R.N.) or a licensed practical nurse (LP.N.), for not more than three (3) hours per day,
to the following:
subject9
a the care must be ordered by a Physician;
b. the care must not be primarily for the convenience of the patient or the patient's family;
c. time spent bathing, feeding,transporting, exercising or moving the patient, giving oral medication
or acting as a companion or sitter or homemaking,will not be considered for benefit payment under
this provision;
d. the care must not be provided by a nurse who is an immediate relative by blood, marriage or
adoption, or a member of the Covered Person's household;
e. the patient must be physically unable to be transported to receive medical care;
f. the care must not be provided in a Hospital, a skilled nursing facility, an intermediate care facility, a
residential care facility or a domiciliary facility.
13. Renal Dialysis: Services for renal dialysis including all charges for home dialysis equipment and
disposable supplies. Benefits will also be provided for one session of dialysis training or counseling. We
will be primary for a maximum of fifteen (15) months or until Medicare assumes primary responsibility for
benefits.
14. Cardiac Rehabilitation Program: Cardiac Rehabilitation isdefined as the use of various modalities of
treatment to improve cardiac function-as well as tissue perfusion and oxygenation through which selected
patients are restored to and maintained at either a pre-illness level of activity or a new and appropriate
level of adjustment.
a. Benefit Provision:
(1) Benefits will be provided for up to six weeks each calendar year for Hospital Outpatient
Cardiac Rehabilitation Program Services, for up to three (3) sessions per week.
(2) Covered Hospital Services: All services defined as Covered Services for Outpatient care by
Part V of this Contract. In addition to such services, the following shall be Covered Services
when provided as part of the Cardiac Rehabilitation Program and reimbursed at the Hospital's
Maximum Benefit Amount:
(a) Initial cardiac rehabilitation evaluation;
(b) Exercise sessions;
(c) Concurrent monitoring during the exercise session for high risk patients.
9836 Rev. 5/1/90 22
- I
(3) Covered Physician Services: All Covered Physician Services as defined by Part VI which are
provided to an Outpatient
(4) No coverage will be provided for:
(a) Diet or dietetic instructions;
(b) Smoking cessation classes;
(c) Medication instruction;
(d)Weight control and/or instruction;
(e) Recreational therapy, educational therapy, or forms of non-medical self-care or self-help
therapy;
(f) Environmental control items such as air conditioners and dehumidifiers.
b. Covered Person Eligibility: Covered Persons will be eligible for the benefits provided by this
paragraph 14, iif they meet the following criteria:
(1) Diagnoses: Services will be provided after the following:
(a)An acute myocardial infarction during the preceding twelve months;
} (b) Coronary bypass surgery.
(2) The patient's condition must be such that Cardiac Rehabilitation can only be carried out
safely under the direct, continuing supervi;;ion of a Physician and in a controlled hospital
environment.
c. Cardiac Rehabilitation Program-Qualifications:
(1) The Cardiac Rehabilitation Program must be accredited by the Joint Commission on the
Accreditation of Health Care Organizations.
15. Physical Rehabilitation Program: Physical Rehabilitation is defined as the restoration of a person who
was totally disabled as the result of an Illness or Injury to a level of function which allows that person to live
as independently as possible. A person is totally disabled when such person has physical disabilities and
needs active assistance to perform the normal activities of daily living, such as eating, dressing, personal
hygiene, ambulation and changing body position.
a. Benefit Provisions: Benefits will be provided for up to sixty (60) Inpatient days per calendar year
for Covered Services as defined by this paragraph 15. Such benefits may be preauthorized as set
forth in paragraph f. The Provider must meet the requirements of the Physical Rehabilitation
Program, as defined herein.
b. Covered Hospital Services: All services defined as Covered Services for inpatient care by Part V
of this Contract. In addition to such services,the following shall be Covered Services when provided
as part of the Physical Rehabilitation Program:
(1) Recreational therapy;
(2) Social service counseling;
(3) Prosthetic devices and fitting;
�:.
9836 Rev. 5/1/90 23 - �
(4) Psychological testing.
c. Covered Physician Services: All Covered Physician Services as defined by Part VI which are
provided to an Inpatient.
d. Covered Person Eligibility: Covered Persons will be eligible for the benefits provided by this
paragraph 15, iif they are totally disabled and meet the following criteria:
(1) Diagnosis: Services will be provided for patients who are totally disabled and who meet
defined specifications for coverage as determined by us.
(2) The Covered Person must have intense daily involvement in two or more of the following
treatment modalities:
(a) Physical therapy;
(b) Occupational thera
py;
(c) Speech therapy.
(3) Inpatient rehabilitation must immediately follow an acute hospitalization.
(4) Benefits for further rehabilitation will stop when:
(a) further progress toward the established rehabilitation goal is minimalunlikely;
or unl i,cely;
(b) such progress can be achieved in a less intensive setting;
(c) treatment could be continued on an Outpatient basis.
e. Provider Requirements: For benefits to be available for a Physical Rehabilitation Program, the
Provider must be accredited by the Committee on the Accreditation of Rehabilitation Facilities
(CARE), or otherwise approved by us.
f. Preauthorization Procedure: Benefits may be preauthorized. Preauthorization occurs as follows:
(1) Initial Preauthorization:A Notice of Admission form may be completed and submitted by the
Hospital or Provider to us prior to or within five (5) days of the date of admission to the Program.
initial approval will be limited to a maximum of thirty (30) days. The history and physical,
Physician's orders and progress notes, nurses' notes, and therapy notes are to be submitted
with the Notice of Admission. If the admission is not approved by us, benefits may not be
provided for those days prior to the receipt of the Notice of Admission.
(2) Extension of Benefits: After the initial approval, requests for an extension of benefits must
be submitted by the Hospital or Provider to us every fifteen (15) days. Subsequent approvals
are limited to a maximum of fifteen (15) days. The Physician's orders and progress notes,
nurses' notes,therapynotes, and therequest
for an extension of benefits
are to be submitted
prior to or not later than the day through which benefits have been approved. If the extension
request is not received on a timely basis and the extension is not approved by us, benefits will
not be guaranteed beyond the previous approval date.
We will notify the Provider by telephone and in writing about the initial approval or disapproval of
coverage, as well as any subsequent approval or disapproval for an extension of benefits. We will
notify the Covered Person in writing about the initial decision and any subsequent approval or
disapproval. If benefits are not preauthorized, claims for such benefits may be denied if the Covered
9836 Rev. 5/1/90
24
Person's condition or the program does not meet the criteria established by this paragraph 15 for a
Physical Rehabilitation Program.
PART XIII. EXCLUSIONS AND LIMITATIONS
A. Benefits are not provided by this Contract for the following:
1. Services not specifically covered by this Contract, nor amounts above charges for Covered Services. If
a Non-Covered Service is provided to a Covered Person,the responsibility for payment rests with the
Covered Person. Non-Covered Services include, but are not limited to any service for, or related to:
a. Audiological examinations; audiant bone conductors; or hearing aids and their fitting;
b. Blood, blood plasma or blood derivatives or fractionates, or services by or for blood donors,
except administrative charges for blood furnished to a Hospital by the American Red Cross or a
county blood bank and used for a Covered Person;
c. Cosmetic or restorative surgery unless required as a result of an Illness or Injury occurring after
the effective date of coverage;
d. Detection or correction by manual or mechanical means of structural imbalance, distortion, or
. subluxation in the human body for the purpose of removing nerve interference and its effects where it
is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;
e. Eye examinations, eye refractions, eyeglasses or contact lenses, eye exercises or visual training
(orthoptics) except as allowed by Part XII, paragraph 11;
f. Hospital or Physician charges for standby availability;
g. Personal expenses while hospitalized, such as guest meals, TV rental and barber services;
h. Routine or periodic examinations, regardless of age, including well baby care;
i. Custodial care;
j. Treatment primarily for obesity or for weight reduction, regardless of diagnosis, except surgical
operations;
k. Therapy which is primarily of recreational or educational nature, or forms of nonmedical self-care
or self-help training, and any related diagnostic testing;
I. Treatment or removal of corns,callosities, or the cutting or trimming of nails;
m. Fertility testing and related services; artificial insemination; in vitro fertilization; and embryo
transfer services;
n. Interest, sales or other taxes on Covered Services, drugs, supplies or Durable Medical Equipment;
o. Charges made for filling out claim forms or furnishing any other records or information;
p. Charges made while the patient is temporarily out of the Hospital;
q. Psychological counseling services provided by persons other than Physicians or certified clinical
psychologists, or registered nurses, certified master social workers or licensed psychologists working
under the direct supervision of a Physician or certified clinical psychologist;
9836 Rev. 5/1/90 25
r. Marital, family or similar counseling service or educational service;
s. Lodging or travel, even though prescribed by a Physician for the purpose of obtaining medical
treatment, except for ambulance services as provided herein and travel benefits as provided for
under Part X, Organ Transplants;
t. Repairs, maintenance or adjustment of Durable Medical Equipment;
u. Services or care for mental retardation;
v. Music therapy or cognitive therapy;
w. Nutrition care or supplements.
2. Services not considered by us to be payable after review through our Utilization Review Program. Our
Utilization Review Program consists of evaluating the use.of a medical or surgical procedure or service or
the utilization of medical supplies, drugs or Durable Medical Equipment, compared to established criteria,
to determine whether benefits are payable. Benefits will not be provided for services, procedures, drugs,
supplies or Durable Medical Equipment,which are determined by our Utilization Review Program not to be
Medically Necessary, nor for any related service.
If we make final determination of a claim through our Utilization Review Program that a Covered Service
was not Medically Necessary, a PPO Nebraska Hospital, PPO Nebraska Physician, or other PPO
Nebraska Provider agrees not to charge, collect or seek collection from a Covered Person, or anyone
responsible for a Covered Person.
If we make final determination of a claim through our Utilization Review Program, that a Covered Service
was not payable, we will not provide benefits for that service or any related service. If the service was
provided by a Non-PPO Nebraska Provider and that Provider is not participating in another Blue Cross
and Blue Shield of Nebraska program, the expense of that service will be the responsibility of the Covered
Person. Furthermore, the cost of that service will not be considered when we compute the Maximum
Coinsurance Liability of the Covered Person.
3. Benefits will not be provided for services and procedures and any drugs, supplies, or Durable Medical
Equipment which are considered to be Investigative, nor for any related.service.
4. Benefits will not be provided for services and procedures and any drugs, supplies or Durable Medical
Equipment which are considered to be for Cosmetic purposes, nor for any related service.
5. Benefits will not be provided for services and procedures, and any drugs, supplies or Durable Medical
Equipment which are considered by us to be obsolete, nor for any related service. Procedures will be
considered to be obsolete when such procedures have been superseded by more efficacious treatment
procedures, and are no longer considered effective in clinical medicine.
6. Services provided to or for:
a Any dependent of an employee who has a Single Membership;
b. Any person who does not qualify as an Eligible Dependent;
c. Any Covered Person before the effective date of coverage or for a claim for services provided after
the effective date of cancellation or termination;
d. Any Covered Person for any condition for which coverage has not yet become effective because;\ l
of any Contract Waiting Periods.
9836 Rev.5/1/90 26
7. Services for Illness or Injury caused directly or indirectly by war or any act of war, declared or
undeclared, or sustained while performing military service.
8. Services provided in or by: (1) a Veterans Administration Hospital where the care is for a condition
related to military service; or (2) any Hospital or other institution which is owned, operated or controlled by
any government agency or hospital authorities, except where care is provided to non-active duty
beneficiaries in military medical facilities.
9. Services available at government expense,whether or not such benefits are elected, except as follows:
a. With respect to persons entitled for Medicare Part A and eligible for Part B benefits, our obligation
to provide benefits will be reduced by the amount of payment or benefits such person receives from
Medicare. This provision will not apply if the person is still actively at work, and has elected us as the
primary carrier, except as applied to services provided for renal dialysis and kidney transplant
services.
•
b. With respect to persons eligible for benefits under any other government program except
Medicaid, whether or not the person is enrolled, our obligation to provide benefits will be reduced by
the amount of payments a Covered Person is eligible for under such program; all such payments and
benefits shall be charged against the maximum benefit payments as if such benefits had been
provided by this Contract.
10. Services to the extent they are not payable under this Contract because of the application of Part XV,
Coordination of Benefits. -
11. Services for which there is no legal obligation to pay, or for which no charge would be made if this
coverage did not exist. Any charge above the charge that would have been made if no coverage existed;
any service which is normally furnished without charge; or, any service which is not actually provided,
shall be treated as services for which there is no legal obligation to pay.
12. Services covered under any Workers'Compensation or Employers' Liability Law, whether or not the
Covered Person asserts rights to such coverage.
13. Charges for services provided by a person who is a member of the Covered Person's immediate
family by blood, marriage or adoption.
14. Charges for services by a health care provider which are not within his or her scope of practice.
15. Charges in excess of the Maximum Benefit Amount.
16. Charges made separately for services, supplies and material when such services, supplies and
materials are considered by us to be included within the charge for a total service payable under this
Contract.
17. Services provided by a person,firm or corporation who has not obtained a certificate of need, as
required by an applicable certificate of need law.
18. Services not specifically covered, but provided because of Hospital accreditation requirements or
Hospital staff rules or regulations.
19. Services required by an employer as a condition of employment including, but not limited to
immunizations, work physicals and drug tests.
20. An employee or other Eligible Dependent with another Blue Cross and Blue Shield coverage shall be
limited to payment for not more than 100%of the Allowable Charge.
21. Equipment for purifying, heating, cooling or otherwise treating air or water.
9836 Rev.5/1/90 27
•
22. The building or remodeling of a residence.
23. The purchasing or customizing of vans or other vehicles.
24. Orthotic devices.
B. Subject to all other conditions of this Contract, limited benefits are provided for.
1. Oral Surgery and Dentistry (Part IX).
2. Mental Illness, Drug Addiction and Alcoholism (Part VIII).
3. Whole Organ Transplants (Part X).
4. Home Health Aide and Hospice Services (Part XI).
5. Eyeglasses or contact lenses (Part XII).
PART XIV. PROCEDURES FOR FILING A CLAIM
A. Notice of Claim/Proof of Loss: A Covered Person must notify us when they have received health care
services for which this Contract will pay benefits. This notice is called a claim. The claim must give us written
proof of the services provided. The claim may be filed directly by the Covered Person, or the Hospital, the
Physician or whoever provided the service. If the service is provided by a PPO Nebraska Physician, or PPO
Nebraska Hospital, or another PPO Nebraska Provider, the claim will be filed by them. To process a claim,we
must always have the employee's Identification Number and an itemized statement from whoever provided the
care describing the service and showing the amount charged. We are entitled to any additional information
needed to process the claim.
B. Time Limit for Filing a Claim: A claim should be filed within ninety (90) days of the time the services are
provided, or as soon thereafter as is reasonably possible. If the employee does not file a claim within eighteen
(18) months of the date of service,and it was reasonably possible to do so, benefits will not be paid.
IT IS SUGGESTED THAT ALL CLAIMS BE FILED WITH US AS SOON AS POSSIBLE AFTER EXPENSES ARE
INCURRED. PPO NEBRASKA PROVIDERS WILL FILE CLAIMS WITHIN SIXTY (60) DAYS.
C. Claims should be sent to:
Blue Cross and Blue Shield of Nebraska
P.O. Box 3248
Omaha, Nebraska 68180-0001
PART XV. COORDINATION OF BENEFITS
A. This Part limits duplication of benefits for Allowable Expenses so that the total Plan(s) benefits for Allowable
Expenses shall not exceed those expenses.
B. Within this Part,the following definitions apply.
1. Allowable Expense: Any necessary, reasonable and customary item of expense covered in whole or in
part by this Plan or another Plan during a Claim Determination Period. When benefits are in the form of
services rather than cash payments, the reasonable cash value of each service shall be both an Allowable
Expense and a benefit paid. Benefits payable under a Plan include the benefits that would have been
payable had a claim been made. Items of expense under coverages such as dental care, vision care,
prescription drug, or hearing aid programs are excluded from this definition.
9836 Rev.5/1/90 28
2. Automobile No-fault Contracts: Insurance under which benefits are payable by the Insurer for
expenses of Hospital and medical care of Injuries resulting from an automobile accident regardless of
negligence.
3. Claim Determination Period: The period of a calendar year over which Allowable Expenses are
compared with total benefits in the absence of this provision. However, it does not include any part of a
year during which a person has no coverage under this Plan, or any part of a year before the date this
Coordination of Benefits provision or a similar provision takes effect.
4. Insurer: An insurance company, a health maintenance organization, a preferred provider organization,
a dental service corporation, or a nonprofit hospital service corporation.
5. Plan: Any Plan providing benefits or services for or by reason of medical or dental care or treatment,
which benefits are provided by:
a Group, blanket or franchise insurance coverage;
b. Uninsured arrangements of group or group-type coverage;
c. Any coverage under labor management trustee plans, union welfare plans, employer organization
plans, or employee benefit organization plans;
d. Hospital indemnity type coverages written on a non-expense incurred basis to the extent the
benefits available are more than$100.00 per day;
e. Both group and individual Automobile No-fault Contracts;
f. Group or group-type coverage through HMOs and other prepayment, group practice and
individual practice plans.
Plan does not include:
g. Grammar school, high school, or college accident-type coverages,written on either an individual,
group, blanket, or franchise basis;
h. Individually underwritten and issued Hospital, Expense or Dread Disease policies;
i. Hospital Indemnity Type Coverages written on anon-expense basis to the extent the benefits
available are equal to, or less than, $10G per day;
j. Non-Group Individual or Family insurance or subscriber contracts; '
k. Non-Group Individual or Family coverage through Health Maintenance Organizations;
I. Non-Group Individual or Family coverage under other prepayment, group practice or individual
practice plans.
m. Plans whose benefits, by law,are in excess to those of any private insurance program or other
nongovernmental program.
6. Primary Plan: The Plan which will determine allowable benefits without regard to other covered
Allowable Expenses.
7. Secondary Plan: The Plan which will determine allowable benefits for the balance of the remaining
charges in the Claim Determination Period.
9836 Rev.5/1/90 29
•
8. Primary Plan/Secondary Plan: The order of benefit determination rules state whether this Plan is a
Primary Plan or Secondary Plan as to another Plan covering the person.
a. When this Plan is a Primary Plan, its benefits are determined before those of the other Plan and
without considering the other Plan's benefits;
b. When this Plan is a Secondary Plan, its benefits are determined after those of the other Plan and
may be reduced because of the other Plan's benefits;
c. When there are more than two Plans covering the person, this Plan may be a Primary Plan as to
one or more other Plans, and may be a Secondary Plan as to a different Plan or Plans.
C. Order of Benefits:
1. If benefits are payable under any other Plan or No-Fault Automobile Insurance coverage which does
not provide for Coordination of Benefits, the insurer providing such other coverage will be the Primary
Carrier.
2. Whenever the benefits payable under any other Plan are determined with regard to the benefits payable
under this Contract, then the Primary Carrier will be the organization which is the only one which satisfied
the first one of the following tests by providing a Plan to the Covered Person:
a. as an employee (other than as a dependent);
b. as a child of the parent where the parents are not separated or divorced whose birthday falls •
earlier in the year. Where both parents have the same birthday,the Primary Carrier will be the one
which covered the parent for the longer period of time. However, if the other Plan does not have this
rule, but instead has a rule based on gender,the rule in the other Plan will determine who is the
Primary Carrier.
c. as a child of the custodial parent where the parents are divorced or separated, then as the child of
the spouse of the parent with custody and then as a child of the parent not having custody.
However, if there is actual knowledge that the divorce decree requires one parent to be responsible
for health care expenses,the Primary Carrier will be the Plan provided by that parent;
d. as an employee who is neither laid off nor retired (or as that employee's dependent) before those
of the Carrier which covers that person as a laid off or retired employee (or that employee's
dependent). If the other Health Benefit Coverage does not have this provision and, if as a result,the
Carriers do not agree on the order of benefits,this section is ignored.
e. a COBRA beneficiary who is continuing coverage in accord with federal law.
f. if none of the above rules determines the order of benefits, the benefits of the Plan which covered
an employee or subscriber longer are determined before those of the Plan which covered that person
for the shorter time.
D. To properly administer this Part,we may obtain from or release to any insurance company or other
organization or person, any information necessary to determine whether this Part or any similar Part in any
other Contract applies. Any person who claims benefits under this Contract agrees to furnish the Plan
information that may be necessary to effect Coordination of Benefits.
E. If another Plan makes payment which we should have made, then we have the right to pay to such other
Plan any amounts determined to be necessary. Amounts paid to other Plans in this manner will be considered
benefits paid hereunder. This Plan is discharged from liability hereunder to the extent of any amounts so paid.
C' V
F. If we make larger payments than necessary, then we have the right to recover any excess from any insurer,
any other organization, or any person to or for whom such payments were made, including the employee. _.
9836 Rev.5/1/90 30
G. The Plan's duty hereunder is limited to making a reasonable effort to avoid liability as the Primary Plan in
appropriate cases brought to its attention;to making reasonable efforts to compute the amount payable under
any other Plan; and to making reasonable efforts to recover any excess payments made by it.
H. If this Plan is the Secondary Plan, benefits under this Plan must be computed as if this provision does not
exist. After calculating the benefits as though other coverage did not exist, this Plan may reduce its benefits so
that the total benefits paid or provided by all Plans during a Claim Determination Period are not more than total
Allowable Expenses. The amount by which this Plan's benefits has been reduced will be used by us to pay
Allowable Expenses, not otherwise paid,which were incurred during the Claim Determination Period by the
Person for whom the claim is made. As each claim is submitted, this Plan determines its obligation to pay for
Allowable Expenses based on all claims which were submitted up to that point in time during the Claim
Determination Period.
•
I. If this Plan is the Primary Plan,there will be no reduction of benefits under this Part.
PART XVI. SUBROGATION
A. Subrogation is our limited right to recover benefits paid for Covered Services provided as the result of Injury
or Illness which was willfully or negligently caused by another person. If we pay benefits for Covered Services
provided to a Covered Person as the result of an Injury or Illness,we are allowed to be reimbursed the amount
paid for such services by the Covered Person if the Covered Person or the person who has a right to recover
for a Covered Person (usually a parent or spouse), recovers the cost of such services from the person who
caused the Injury or Illness or from that person's liability insurance carrier.
B. The Covered Person agrees to assist us in any way necessary to recover such payments. The Covered
Person agrees not to interrupt or prejudice our right to recover.
C. If the Covered Person refuses or fails to comply with this Part,we can cancel coverage, including that of any.
covered dependents.
D. Subrogation does not apply to recoveries made by Covered Persons from No-Fault Insurance. Recoveries
made by the Covered Person from No-Fault insurance are subject to Coordination of Benefits (Part XV).
PART XVII. WORKERS' COMPENSATION
Benefits for services provided as the result of Illness or Injury arising out of employment for which an employer
is required to furnish or pay for, pursuant to Workers' Compensation laws, are not payable under this Contract.
(See Part XIII, Exclusion Number 12. .In certain instances, benefits for such services are paid in error under
this Contract. If we pay for such services,we are entitled to reimbursement for such payments from the
Covered Person. This reimbursement may be funded from any recovery made from the employer, or the
employer's Workers' Compensation carrier.
PART XVIII. STANDARD PROVISIONS
A. CERTAIN DEFENSES: All statements, in the absence of fraud, made by you or the Covered Person will be
deemed representations and not warranties. No such statements will void coverage or reduce the Contract
benefits unless contained in the attached Application or the employee's Enrollment Form filed with us.
B. LEGAL ACTIONS: The employee cannot bring a legal action to recover under the Contract for at least sixty
(60) days after written proof of loss is given to us. The employee cannot start a legal action after three (3) years
from the date written proof of loss is required.
C. ADDRESSES FOR NOTICE: Our address is 7261 Mercy Road, Omaha, Nebraska, 68180-0001. The
Covered Person's address is the most recent address appearing on our records. Your address is the address
shown on the application.
9836 Rev. 5/1/90 • 31
D. CHANGE OF OCCUPATION: No change in coverage will be made if the employee or any Eligible
Dependent changes occupations except as stated in the eligibility provision on unmarried children attending
school. �.l
E. CONFORMITY WITH STATUTES: Any Contract provision which does not conform with the laws of
Nebraska or the United States is hereby amended to conform.
F. TIME OMIT ON CERTAIN DEFENSES: After two (2) years from the Contract effective date, no
misstatements, except fraudulent misstatements made in the Contract application will be used to void the
•
Contract or deny a claim for loss incurred after the expiration of such two (2) year period. No claim for loss
that starts more than two (2) years after the Contract effective date will be reduced or denied on the grounds
that a condition not excluded from coverage existed prior to the effective date of the Contract.
G. INTERPRETATION AND DETERMINATION OF BENEFITS: If a group is self-funded or partially self-
funded, Group Applicant grants to Blue Cross and Blue Shield of Nebraska discretionary authority to
determine eligibility for benefits and to construe and interpret the terms of the Plan, consistent with the
terms of this document. The decisions of Blue Cross and Blue Shield of Nebraska shall be final and
binding subject to appeal to Blue Cross and Blue Shield of Nebraska under its review process. Benefits
will be paid or denied consistent with the Benefit Plan based on this determination.
PART XIX. DEFINITIONS •
The definitions contained in this glossary are of terms used in this Contract.
Alcoholism or Drug Treatment Center: A facility licensed by the Department of Health as an Alcoholism or
Drug Treatment Center which is not licensed as a Hospital, and which is used to provide residential care,
t,eatment, services, maintenance, accommodation or board in a group setting primarily and exclusively for
individuals having a dependency or addiction to the use of alcohol or drugs. •
Allowable Charge: The Allowable Charge for Covered Services provided by a Hospital or other licensed
facility is the DRG amount or the billed charge. The Allowable Charge for a Covered Service provided by a
Physician or other licensed professional provider is the lesser of the billed charge, the Reimbursement
Schedule amount if by a PPO Nebraska Physician, or the Maximum Benefit Amount. The Allowable Charge for
any other Covered Service is the billed charge.
Certificate: A booklet summarizing Contract information provided to each employee.
Coinsurance: The amount of each Allowable Charge which the Covered Person must pay. This amount is
computed as a percentage of the Allowable Charges.
Company: Blue Cross and Blue Shield of Nebraska.
Consultations: Physician's services for a patient in need of specialized care requested by the attending
Physician who does not have that knowledge.
Cosmetic: Services, procedures, surgery and any drugs, supplies or Durable Medical Equipment provided to
improve the patient's physical appearance,while not materially improving the patient's essential bodily
functions, regardless of emotional or psychiatric factors.
Covered Person: Covered employee or employee's Eligible Dependents.
Covered Services: Hospital, medical or surgical services, drugs, supplies, Durable Medical Equipment, or
other health care services, for which this Contract provides benefits, provided to a Covered Person while this
Contract is in effect.
Custodial Care: Care given to a patient who:
9836 Rev. 5/1/90 32
1. is mentally or physically disabled; and
2. needs a protected, monitored or controlled environment or assistance to support the basics of daily
living, in an institution or at home; and
3. is not under active and specific medical, surgical or psychiatric treatment which will reduce the
disability to the extent necessary to allow the patient to function outside such environment or without such
assistance,within a reasonable time,which will not exceed one year in any event
A Custodial Care determination may still be made if the patient is under the care of a Physician; or services are
being ordered to support and generally maintain the patient's condition, or provide for the patient's comfort, or
assure the manageability of the patient; or the ordered services are being administered by a registered or
licensed practical nurse.
Deductible Amount: An amount which the Covered Person must pay each calendar year for Covered
Services before benefits are payable by this Contract.
Durable Medical Equipment: Equipment and supplies Medically Necessary to treat an Illness or Injury, to
improve the functioning of a malformed body member, or to prevent further deterioration of the patient's
medical condition. Durable Medical Equipment includes such items as prosthetic devices, orthopedic braces,
crutches and wheelchairs.
Eligible Dependent: •
1. Employee's spouse unless the marriage has been ended by a legal, effective decree of dissolution,
divorce or separation.
2. Employee's unmarried children 18 years of age or less who are chiefly dependent upon the employee
for support and maintenance;
a. A child is-chiefly dependent upon the employee for support and maintenance-so long as the
employee provides more than one-half of the child's support Child includes stepchild, adopted child,
and grandchild, who lives with the employee in a regular child-parent relationship, but not foster
child.
b. Reaching age 19 while a child is a Covered Person will not end the child's coverage under this
Contract as long as the child is,and remains, both:
(1) incapable of self-sustaining employment by reason of mental or physical handicap; and
(2) chiefly dependent upon the employee for support and maintenance.
We must receive proof of the requirements of(1) and (2) from the employee within thirty-one (31)
days of the child's reaching age 19 and thereafter as we require (but not more often than yearly after
two years of such handicap). Determination of eligibility under this provision will be made by us.
3. The employee's unmarried children 23 years of age or less who are chiefly dependent upon the
employee for support and maintenance and are in full time attendance at an educational institution which
has a curriculum, faculty and student body in attendance. Coverage hereunder will continue during
normal school vacation periods if the child is enrolled for the following term.
4. Extension of Student Coverage for Disability: Coverage of such a student who becomes disabled after
age 19 will continue hereunder if:
a.The child is incapable of attending school by reason of mental or physical handicap. This
determination will be made by us.
9836 Rev.5 1 90
� � 33
r A
b. Proof of such disability is furnished to us by the employee within thirty-one (31) days of the disability. •
c.The extended coverage will end:
1
(1) Two (2) years following the start of the disability; or
(2) When the child is able to attend school full time; or
(3) When the employee's coverage under this Contract ends;
whichever occurs first.
d. The extended coverage will be subject to all the Contract provisions.
Freestanding Ambulatory Facility: A facility for the treatment of patients, which is not connected with offices
of an individual or group practice of Physicians, nor licensed as a part of a Hospital, which provides those
facilities and degree of care generally found in and required of licensed Hospitals, except for overnight care.
Group Applicant: The group that arranges this coverage.
Hospital: A Hospital is an institution or facility licensed by the State of Nebraska or the state in which it is
located,which provides medical and surgical diagnostic and treatment services for compensation to persons
with an Illness, Injury or Pregnancy, under the supervision of a staff of Physicians licensed to practice medicine
and surgery and provides 24-hour per day nursing service. This definition of Hospital includes facilities
licensed as general acute care hospitals, short-term hospitals, psychiatric hospitals, and emergencyhospitals 2 as defined by Nebraska statutes. ) S
This definition of Hospital does not include:
1. a long-term care hospital or facility, primarily providing skilled or non-skilled nursing care, or a
residential care or domiciliary care facility;
2. a rehabilitative hospital which is an inpatient facility operated for the primary purpose of assisting in the
rehabilitation of disabled persons;
primary i•
3. an institution whose
p ry purpose is the furnishing of food, shelter, training or educational or non-
medical personal services;
4. an alcoholism treatment center;
5. a drug treatment center;
6. a mental health center or a place for mental or physical rehabilitation, other than a psychiatric hospital
as defined by Nebraska law.
Illness: Bodily disorder or disease.
Injury: Accidental physical harm.
Inpatient: A patient admitted to a Hospital for bed occupancy for more than twenty-four(24) hours to receive
necessary medical care.
investigative Treatment: Treatment is considered Investigative when the service, procedure, drug,
treatment modality has progressed to limited human application, but has not achieved recognition as being
proven and effective in clinical medicine.
9836 Rev.5/1/90 `I
34
Such recognition may be achieved through the following:
1. Final approval for the use of a specific service, procedure, drug or treatment modality for a specific
diagnosis from the appropriate governmental regulatory body;
2. Scientific evidence permitting a consensus conclusion recognizing the effectiveness of the specific
service, procedure, drug or treatment modality on health outcomes for a specific diagnosis.
We will determine whether a service, procedure,drug or treatment modality is Investigative.
Master Group Application: A form provided by us, executed by you, and accepted by us which becomes a
part of this Contract. The Master Group Application contains all of the variables which you must elect to
determine the coverage for the Covered Persons of your group.
Maternity Admission: Inpatient Hospital admission for PregnarScy.
Maximum Benefit Amount:A benefit amount which is the lower of the Provider's billed charge for a Covered
Service or the maximum amount determined by us to be reasonable. We may consider the charges submitted
by providers for like procedures, a relative value scale which compares the complexity of services provided, or
any other factor we deem necessary.
Medical Emergency: The sudden and unexpected onset of symptoms or the exacerbation of a chronic
condition which presents an acute, severe, and immediate life threatening situation requiring medical attention.
Medically Necessary: The services, procedures,drugs, supplies or Durable Medical Equipment provided by
the Physician, Hospital or other health care provider, in the diagnosis or treatment of the Covered Person's
Illness, Injury, or Pregnancy,which are:
1. Appropriate for the symptoms and diagnosis of the patient's Illness, Injury or Pregnancy; and
2. Provided in the most appropriate setting and at the most appropriate level of services. The most
appropriate setting and most appropriate level of services is that setting and that level of services which is
the most cost effective without adversely affecting the Covered Person's medical condition. When this test
is applied to the care of an Inpatient, the Covered Person's medical symptoms or condition must require
that treatment cannot be safely provided in a less intensive medical setting; and
3. Consistent with the standards of good medical practice in the medical community of the State of
Nebraska; and
4. Not provided primarily for the convenience of any of the following:
a. the Covered Person;
•
b. the Physician;
c. the Covered Person's family;
d. any other person or health care provider; and
5. Not considered to be unnecessarily repetitive when performed in combination with other diagnoses or
treatment procedures.
We will determine whether services provided are Medically Necessary. Services will not automatically be
considered Medically Necessary because they have been ordered or provided by a Physician.
9836 Rev. 5/1/90 35
1
Medicaid: Grants to States for Medical Assistance Programs, Title XVIII of the Social Security Act, as
amended.
Medicare: Health Insurance for the Aged and Disabled,Title XVIII of the Social Security Act, as amended.
Membership Unit: The membership option selected by the employee identifying the group of persons to be
provided coverage under this Contract.
Mental Illness: A pathological state of mind producing clinically significant psychological or physiological
symptoms (distress) together with impairment in one or more major areas of functioning (disability) wherein
improvement can reasonably be anticipated with therapy. In addition, Mental Illness includes alcoholism, drug
abuse and other controlled substance (drug) abuse.
Non-PPO Nebraska Hospital: A Hospital which has not contracted with us to provide services as a part of the
PPO Nebraska Provider network.
Non-PPO Nebraska Physician: A licensed practitioner of the healing arts who has not contracted with us as a
part of the PPO Nebraska Provider network.,
Non-PPO Nebraska Provider: A licensed practitioner of the healing arts, or qualified provider of health care
services, supplies, or Durable Medical Equipment who has not contracted with us as a part of the PPO
Nebraska Provider network.
Outpatient: A person treated in the Outpatient department or emergency room of a Hospital, or in a Free
Standing Ambulatory Facility, or a Physician's office.
Participating Provider: A licensed practitioner of the healing arts, or qualified provider of-health care services,
supplies, or Durable Medical Equipment who has contracted with us to provide services, supplies or Durable
Medical Equipment.
Physical Rehabilitation: Services provided primarily to improve the patient's ability to function in the activities
of daily living, such as bathing,walking, using the toilet, eating, dressing, or homemaking.
Pregnancy: Includes obstetrics, abortions, threatened abortions, miscarriages, premature deliveries, ectopic
pregnancies, or other conditions or complications caused by Pregnancy. A complication caused by
Pregnancy is a condition that occurs prior to the end of the Pregnancy, distinct from the Pregnancy, but
caused or adversely affected by it. Post-partum depression and similar diagnoses are not considered
complications of Pregnancy as that terminology is used in this Contract.
PPO Nebraska Hospital: A Hospital which contracts with us to provide services as a part of the PPO
Nebraska Provider network.
PPO Nebraska Physician: A licensed practitioner of the healing arts who has contracted with us to provide
Covered Services as a part of the PPO Nebraska Provider network.
PPO Nebraska Provider. Any other licensed practitioner of the healing arts, or qualified provider of health
care services, supplies, or Durable Medical Equipment who has contracted with us to provide services,
supplies or Durable Medical Equipment as a part of the PPO Nebraska Provider network.
Treatment Center: A licensed Alcoholism or Drug Treatment Center.
a
9836 Rev.5/1/90 36
Erfl
ENDORSEMENT
CITY OF OMAHA
P P0 NEBRASKA
This Endorsement is attached to, and becomes a part 01, the City of Omaha Master Group Contract #9e36
Rev. 5/1/90. Such contract is amended as follows:
1. Part I,C, Waiting Periods, paragraph 1(a) and (b) Is deleted and replaced as follows:
1. No benefit payment will be made for Covered Services for the following conditions or procedures
unti Blue Cross and Blue Shield of Nebraska coverage has been in effect for at least 270 continuous
days:
a. Pre-existing Conditions, which are defined as any illness or Injury for which a Physician
prescribed medication or rendered medical treatment or advice within twelve (12) months prior to
the effective date of coverage. A Pre-existing Condition is also defined as an Illness which
exhibited symptoms within twelve (12) months prior to the effective date of coverage or a
previous injury which exhibited symptoms or complications within twelve (12) months prior to the
effective date of coverage, either of which would lead a prudent person to seek medical
treatment or advice.
b. Congenital defects or birth abnormalities, which are defined as conditions existing at or from
birth which Is a deviation from the norm such as a dotting, protruding ears, birthmarks,webbed
fingers or toes, and other conditions normally considered congenital defects or birth
abnormalities.
• c. Sterilization, tonstlectomy,appendectomy, adenoldectomy, mpacted teeth, myringotomy _..
or tympanoplasty.
d. Colporrhaphy,cdpoplas y, cystocele (repair of anterior vaginal watt), perineorrhaphy,
perineopiasty, rectoceie (repair of posterior vaginal wall), total or partial salpingectomy,total or
partial oophorectomy, hysterectomy or myomectomy.
e. Inguinal, u mbfical or femoral hernias, acne, hemorrhoids, varicose veins, duodenal or
gastric ulcers, gall bladder disease, including gallstones, medical or surgical treatment of thyroid
disease.
•
2. Part N,D, Covered Person's Maximum Coinsurance Liability, is amended to provide that:
Coinsurance Amounts paid by a Single or Family Membership for Covered Services provided for
Mental Illness, Drug Addiction and Alcoholism, Organ Transplants and Home Health Aide and Hospice
y$) be considered in computing the Maximum Coinsurance Liability.
3. Part IV,F, Precertification and Concurrent Review,Is amended at paragraph 1 to provide that:
if a Covered Person does not obtain precertif►cation,the Allowable Charges otherwise considered for
benefit payment by this Contract for Hospital or Treatment Center Covered Services associated with
this Inpatient admission wit be reduced by$500.00.
if inpatient precertfficatlon of benefits is denied, and the Covered Person is admitted to the Hospital or
Treatment Center,the Allowable Charges considered for benefit payment under this Contract for a
Covered Services associated with this admission will be reduced by fifty percent(50%).
i
MR-5 1
99-034 2/91 .
Attu! (.K
Paragraph 2 of.this Part V,F, is unerxied to provide that: '
•
Mowable Charges considered for benefit payment for Covered Services provided during any
period of inpatient cue which Wends beyond the length of stay prey by us wilt be reduced by
fifty per (5 )
4. Part VI,B, Covered Physician's Services, paragraphs 1 (a) and (b), ors deleted and replaced as
follows:
a. When multiple or bilateral surgical procedures which add significant time or complexity to patient
care are performed at the same operative session, the total benefits shall be the amount payable for
the major procedure plus: (1) fifty percent (50%) of the amount payable for the secondary procedure If
only one incision Is required, or (2) seventy-five percent (75%) W a separate Incision is required.
b. When an Incidental procedure such as an Incidental appendectomy, tysis of adhesions, excision
of previous scar, or puncture of ovarian cyst, Is performed through the same Incision as for other
surgery, the amount payable shall not exceed ten percent (10%) of the normal surgical allowance for
the Incidental surgery.
c. When a surgical procedure Is performed in two or more steps or stages, payment MI be limped
to the amount provided for a single procedure.
5. Part Vll, Benefits for Maternity, paragraph A, Is amended to provide that:
Benefits for maternity are not available for a dependent daughter.
6. Part VIII, Benefits for Mental Illness, Drug Addiction and Aicohollsrn, paragraph A, Covered Services, is
deleted and replaced as follows:
A. Covered Services: Covered SeMces.for the acute care of Mental Illness, drug addiction or
alcoholism, or any combination thereof, shall be those Hospital services listed In Part V, and those
Physician services listed in Part Vi. Benefits for the Outpatient treatment of drug addiction and
alcoholism are available only for the programs specified at the facllties identified in Attachment A to
this Endorsement. Benefits veil not be provided for treatment modalities which are Identified as
Noncovered Services in Part XiII of this Contract.
Paragraph B of this Part V11I, Inpatient and Day Cars, is amended to remove the thirty(30) day limitation
per calendar year for Inpatient treatment.
Paragraph C of this Part Vii1, Payment for Outpatient Services, is amended at subparagraph 1, PRO
Nebraska Provider,to provide the .
Benefits wil be paid by us for such Covered Services at 90%cf the Allowable Charge. The Covered
Person is responsible for payment cf the Deductible, the 10%Coinsurance Amount and charges for
Noncovered Services-
This paragraph C is further amended at subparagraph 2, Non--PRO Nebraska Provider, to provide that:
Benefits will be paid by us for such Covered Services at 80%of the Allowable Charge. The Covered
Person is responsible for payment of the Deductible,the 20% Coinsurance Amount, any amount in
excess of the Maximum Benefit Amount,and any charges for Noncovered SeMcea.
> 034 2/91
7. Part LX, & c efka for Orr Surgery and Dentistry, paragraph 5.4 is deleted;and paragraph 5.5
deleted and replaced as follows:
6. Al other procedures or treatments irrvotving the teeth or structures directly related to or
supportkv the teeth, hduding the gums and alveolar processes.
& Part XII, Benefits for Other Covered Services and Supplies, paragraph A3 is deleted and replaced as
follows:
3. Outpatient physical therapy provided by a licensed physical therapist or other qualified person
under the direct supervision of a Physician.
8. Part XII, Benefits for Other Covered Services and Supplies, paragraph A.12 Is amended to delete the
three (3) hour limitation for skilled nursing care. All other provisions of this paragraph remain the same.
10. Part XIII, Exclusions and Limitations, paragraph A1.m. is'deleted and replaced as follows:
m. Artificial insemination, and related services.
•
11. Part XIII, Exclusions and Limitations, Is amended to add at paragraph A.1:
x. Services for voluntary abortions, unless the attending Physician certifies that the abortion was
necessary to safeguard the life of the woman, or that the unborn chad's viability was threatened by
continuation of the Pregnancy. This exclusion does not apply to medical complications arising from a
voluntary abortion.
12. Part XIV, Procedures for Fling a Claim, paragraph B, Ia deleted and replaced as follows:
B. A claim shafd be fled within 90 days of the time the services are provided, or as soon thereafter
as is reasonably possible. if the employee does not file a claim within twenty-four (24) months of the
dale of service, and k was reasonably possible to do so, benefits will not be paid.
•
•
MR-5 '
14-034 2/91
saris ?
•
•
ATTACHMENT
BESafi M
Immanuel Alcoholism Treatment Center Outpatient Treatment Program
Immanuel Medical Center
6901 North 72nd Street
Omaha, Nebraska 68122
Chemical Dependency Services Outpatient Treatment Program
Mercy Hospital
800 Mercy Drive
Council Bluffs, Iowa 50501
Lincoln General Hospital Outpatient Treatment Program
Independence Center •
2300 South 16th Street
Uncoln, Nebraska 68502
•
St. Joseph Center for Mental Health Outpatient Treatment Program
819 Dorcas Street
Omaha, Nebraska 68108
Midlands Community Hospital Outpatient Treatment Program
Highway 370 & South 84th Street
Papiillon, Nebraska 68046
EXCLUSIONS AND UMITATIONS:
1. No patient shall be entitled to more than three (3) admissions per lifetime to any one or a combination
of the approved treatment programs listed above.
2. After completing a program, the patient may not attend the same program or any other of the
approved programs unless there is a 180-day lapse from one of the approved outpatient programs or
an approved inpatient program.
q
EXHIBIT "C"
This exhibit itemizes the fees and expense reimbursements Blue Cross and Blue Shield of
Nebraska is entitled to pursuant to this Administrative Agreement to which this Exhibit "C" is
attached.
Fees are due and payable on or before the 15th of the calendar month, commencing on or
before January, 1997. Fees are based on the existing enrollment at the end of the month prior to the
assessment.
Administrative Service Only(ASO) -Paid basis: including preferred
provider organization (PPO) network charges per employee per
month:
January 1, 1997 to December 31, 1997
$18.75 per employee per month
January 1, 1998 to December 31, 1998
$19.60 per employee per month
January 1, 1999 to December 31, 1999
$20.50 per employee per month
Charge for run out after January 1, 1997
7.00%
In-hospital pre-certification per effected employee per month:
January 1, 1997 to December 31, 1997
$2.25 per employee per month
January 1, 1998 to December 31, 1998
$2.35 per employee per month
January 1, 1999 to December 31, 1999
$2.45 per employee per month
Organ transplant per level of coverage per month:
January 1, 1997 to December 31, 1997
$0.75 per employee per month
$2.25 per family per month .
•
January 1, 1998 to December 31, 1998
$0.84 per employee per month
$2.50 per family per month
January 1, 1999 to December 31, 1999
$0.94 per employee per month
$2.80 per family per month
4841v
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EXHIBIT "D-1"
ENDORSEMENT
CITY OF OMAHA
ORGAN TRANSPLANTS
This Endorsement is attached to, and becomes a part of, the City of Omaha Group Master Contract
#9711 1/80, and Master Group Contract#9836 Rev. 5/1/90. Such contracts are amended to provide
benefits for specified organ transplants as follows:
A. BENEFITS FOR THE COVERED PERSON WHO IS A RECIPIENT OR DONOR:
1. Benefits will be provided for the following Medically Necessary Covered Services;
a. Medical and surgical services;
b. Hospital services;
c. Durable Medical Equipment;
d. Prescription medication;
directly related to, or resulting from, a transplant of the following body organs:
(1) Liver;
(2) Lung;
(3) Heart;
(4) Heart-Lung;
(5) Pancreas;
(6) Kidney
whether the recipient or donor of the organ is a Covered Person.
2. Benefits will be provided for transportation to and from the site of the transplant
procedure for the Covered Person. Such benefits will be limited to the reasonable
cost of land or commercial air transportation.
B. ADDITIONAL BENEFITS -DONATION OF ORGANS: Benefits up to $10,000 will be
provided for the following Medically Necessary Covered Services directly related to, or
resulting from, a transplant procedure listed above.
1. Hospital, medical, surgical or other Covered Services provided to a donor who is a
Noncovered Person;
2. Services provided for the evaluation of organs including, but not limited to, the
determination of tissue matches;
I I I 1
3. Services provided for the removal of organs from nonliving donors;
4. Services provided for the transportation and storage of donated organs.
Benefits provided to Noncovered Persons shall be secondary to benefits provided to those
persons pursuant to their own hospital, medical, surgical, or major medical coverage.
C. PREAUTHORIZATION: All benefit payments for organ transplant procedures must be
preauthorized by us in writing. Preauthorization shall be initiated by the Covered Person,
in writing, to us requesting that benefits be paid for an organ transplant procedure. This
request must be made before the procedure is performed, and be accompanied by
documentation from the Covered Persons Physician demonstrating the Medical Necessity
of the proposed transplant. This request should also indicate at what hospital the transplant
procedure will be performed. This written request should be directed to:
Blue Cross and Blue Shield of Nebraska
Medical Support Department
P.O. Box 3248
Omaha,NE 68180-0001
We will respond in writing advising the Covered Person as to whether benefits are available.
BENEFITS WILL BE REDUCED BY 20% FOR THE ORGAN TRANSPLANT
PROCEDURES LISTED IF SUCH PROCEDURES ARE NOT PREAUTHORIZED.
D. EXCLUSIONS AND LIMITATIONS:
1. All benefits paid pursuant to Parts A and B of this Endorsement will be determined
subject to the terms, conditions, limitations and exclusions, and individual and
lifetime benefit maximums set forth in the benefit provisions of the Administrative
Services Agreement and Contract between the parties which are not in conflict with
the terms of this Endorsement. Benefits provided by this Endorsement will also be
subject to the specific limitations set forth herein.
2. Transplant Benefit Period Limitation: The Transplant Benefit Period is defined as
the period from five days immediately prior to, and one year immediately following,
the transplant procedure (371 days). Benefits will be provided for only one
transplant procedure during the Transplant Benefit Period.
3. Purchased Organs: Benefits will not be provided for the purchase of human organs
which are sold rather than donated to the recipient.
-2-
4. Nonhuman or Artificial/Mechanical Organs: Benefits will not be provided for
transplantation of any nonhuman organ to a human recipient, or the permanent
implantation of an artificial/mechanical organ into a human recipient. This provision
does not apply to the implantation of pacemakers.
E. REIMBURSEMENT
The company will credit the monthly billings sent to the Plan Administrator with 100% of
the actual expenses relating to this transplant which are approved by the Company's
corporate reinsurance carrier during the month after the report from the reinsurer shows the
amount of approved expenses.
F. ORGAN TRANSPLANT - 50/50 ALTERNATIVE
Blue Cross Blue Shield of Nebraska and the City of Omaha would share in the cost of each
organ transplant on a 50/50 basis, up to $100,000 of net paid claims. Claims over the
$100,000 related to the specific organ transplant would be the responsibility of Blue Cross
Blue Shield of Nebraska. For any single transplant claim, the City of Omaha would have a
maximum expense of$50,000. This option is provided as an alternative to the current organ
transplant reinsurance arrangement of 100%.
4840v
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