Summary Plan Description For Ysleta Independent School ... ISD SPD... · This Section is a guide to...

Ysleta Independent School District

Summary Plan Description For


Restatement Date: January 1, 2012

YISD Summary Plan Description Effective 1-1-12

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INTRODUCTION

The Ysleta Independent School District, the Trustee and Plan Administrator of the Plan, issues this summary plan description (“SPD”), which is the legal document that actually governs the Plan. The SPD is issued to describe, in general, the Benefits herein described. These Benefits described herein are made available to Covered Persons based upon their eligibility as defined by the Plan. The Ysleta Independent School District expects Covered Persons to use the Plan to its full extent, in a prudent manner, when a Covered Person is ill or injured. All Covered Persons are advised to contact the Plan Administrator to verify that the Plan will cover the expenses necessary to treat illness or injury PRIOR to starting any suggested plan of medical treatment. The Plan Administrator is: Ysleta Independent School District 9600 Sims Dr El Paso, TX 79925 The TPA (third party claims administrator) is: HealthSCOPE Benefits Inc. HealthSCOPE Benefits Inc P. O. Box 16203 7430 Remcon Circle, Bldg C Lubbock, TX 79490-6203 El Paso, TX 79912 www.healthscopebenefits.com www.healthscopebenefits.com

http://www.healthscopebenefits.com/�

YISD Summary Plan Description Effective 1-1-12

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TABLE OF CONTENTS

Section 1 GUIDE COMPREHENSIVE MEDICAL BENEFITS 1 Section 2 DEFINITIONS 4 Section 3 COMPREHENSIVE MEDICAL PLAN & PHARMACY SCHEDULE OF BENEFITS 16 Section 4 MEDICAL AND PHARMACY EXPENSES 28 Section 5 GENERAL LIMITATIONS AND EXCLUSIONS 33 Section 6 SPECIAL PACKAGE PLAN 38 Section 7 YISD DENTAL PLAN 39 Section 8 ENROLLING FOR COVERAGE AND INDIVIDUAL EFFECTIVE DATE 44 Section 9 INDIVIDUAL TERMINATION OF COVERAGE 46 Section 10 EXTENSION OF COVERAGE FOLLOWING TERMINATION 48 Section 11 COORDINATION OF BENEFITS AND SUBROGATION 57 Section 12 ORDER OF BENEFITS DETERMINATION 60 Section 13 CLAIMS PROCEDURE 62 Section 14 GENERAL PROVISIONS AND INFORMATION 67 Section 15 INDIVIDUAL PRIVACY RIGHTS POLICY AND PROCEDURES 69 Section 16 SPECIFIC PLAN INFORMATION 74

YISD Summary Plan Description Effective 1-1-12 Page 1

Section 1. GUIDE COMPREHENSIVE MEDICAL BENEFITS This Section is a guide to Ysleta Independent School District's Plan Benefits. It explains how to obtain Benefits under the Plan. This Plan allows a Covered Person to receive Plan Benefits by using any Health Care Provider when health care is needed. There are two (2) levels of Benefits under the Plan, each dependent on the choice of Health Care Provider made by the Covered Person at the time medical care is needed. The Plan allows the Covered Person to receive Benefits for Covered Expenses rendered:

1. By Network Providers, or

2. By Non-Network Providers. GENERAL: For Covered Persons, the obligations of the Plan and the Employer shall be fully satisfied by the payment of Benefits in accordance with the Provisions of this plan. Benefits shall be paid for the reimbursement of Covered Expenses incurred by a Covered Person if:

1. The expenses are included in Covered Expenses as provided in this Plan;

2. The expenses are not Excluded Expenses or Limited Expenses;

3. The Benefits payable by this Plan are not reduced by the Coordination of Benefits and Order of Benefit Determination provisions of this Plan;

4. The claims procedures set forth in the Claims Procedure Section have been followed; and

5. All other provisions of the Plan are satisfied.

PATIENT PROTECTION AND AFFORDABLE CARE ACT: This group health plan believes this plan is a “Grandfathered Health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a Grandfathered Health Plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a Grandfathered Health Plan means that your Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, Grandfathered Health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a Grandfathered Health Plan and what might cause a plan to change from Grandfathered Health Plan status can be directed to the Plan Administrator at the following address: Ysleta Independent School District 9600 Sims Dr El Paso, TX 79925 You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthcarereform. This website has a table summarizing which protections do and do not apply to Grandfathered Health Plans. MENTAL HEALTH PARITY: Pursuant to the Mental Health Parity and Addiction Equity Act of 2008, this Plan applies its terms uniformly and enforces parity between covered health care benefits and covered mental health and substance disorder benefits relating to financial cost sharing restrictions and treatment duration limitations. For further details, please contact the Plan Administrator.

http://www.dol.gov/ebsa/healthcarereform�


NETWORK BENEFITS: The Plan offers a broad network of Providers within the network selected by the Plan Sponsor. The Plan provides the highest level of benefits when Covered Persons utilize In-Network Providers. In-Network Providers are those who are contracted with the network indicated on the Identification Card. Services provided by Non-Network Providers will generally be covered at a lower benefit level than services received from an In-Network Provider. If a Covered Person chooses to use the PPO Network portion of the Plan, such Covered Person’s healthcare needs will be coordinated through a network of Preferred Providers. Network Benefits for Covered Expenses will be paid in accordance with the Schedule of Benefits Section, provided the service or supply is:

1. Deemed Medically Necessary; and

2. Provided by a Network Provider. Network Providers are shown on the then current list of such providers contracting with the Network PPO.

Payment for Covered Services rendered by a Network Provider will be based on the Provider’s Allowable Charge. Using a Primary Care Physician, Specialist, or other Healthcare Provider from the PPO Network is a choice. As long as such a Health Care Provider participates as a Network Provider, Network PPO Benefits with respect to Covered Expenses will apply. When a Covered Person uses a Network Provider, the Plan will pay a higher level of benefits as shown in the Schedule of Benefits. NON-NETWORK BENEFITS: If a Covered Person receives services or supplies, the Plan will pay Benefits for Covered Expenses in accordance with the Schedule of Benefits provided the service or supply is:

1. Deemed Medically Necessary; and

2. Provided by a Health Care Provider who is not a Network Provider. If a Covered Person chooses to use Non-Network Providers whether in El Paso or out of El Paso, Non-Network Benefits will apply. Under the Plan, a Covered Person will generally pay higher out of pocket expenses when the Covered Person uses Non-Network Providers, except for the following services which will be paid at the Network Benefit level when the service is performed in a Network facility:

1. Anesthesia;

2. Laboratory, pathology and radiology services;

3. Emergency room Physician services. In addition, the following services or situations, when performed or rendered by a Non-Network Provider, will be covered at the Network Benefit level:

1. Ambulance services

2. Covered Services received by Dependent children who are students and reside outside of the PPO Network’s service area

3. Dependent children of divorced parents who reside outside of the PPO Network’s service area

4. Medical emergency services

5. Covered Services received by the Covered Person outside of the PPO Network’s service area due to the Covered Person traveling

NON-NETWORK PENALTY: If a Non-Network Provider is utilized when an In-Network Provider was available, the Plan will pay Non-Network coinsurance at the primary negotiated contract allowable amount. The eligible amount will not be greater than the prevailing In-Network allowable rate. The following is an example of the penalty calculation:


NON-NETWORK PENALTY CALCULATION EXAMPLE:

Billed Charge Amount $500 Contracted In-Network Rate $400 Non-Network Penalty = Difference is Covered Person’s Responsibility $100 Plan Payment Amount for Non-Network Provider 50% x $400 = $200 Covered Person’s Responsibility for Non-Network Provider 50% x $400 = $200 Plus Non-Network Penalty (Difference in Billed Charges and Contracted In-Network Rate $100

Total Covered Person’s Responsibility $300

PRECERTIFICATION: The Plan requires that a Covered Person or Provider obtain precertification for all Hospital admissions. To obtain precertification, the Covered Person or Provider should contact the telephone number appearing on the back of the identification card. If the Hospital admission is a scheduled admission, precertification notification should be completed within seven (7) business days prior to the scheduled admission. This includes admissions that occur during the weekend. If the Hospital admission is a non-scheduled admission (i.e., an emergency admission), precertification notification should be completed within twenty-four (24) hours of the first business day following the admission date. Failure to obtain precertification in accordance with these guidelines will result in a $300 penalty in connection with the Hospital charges. Precertification is not required when Medicare is the primary coverage for the Covered Person. The Plan will perform Case management services through the Plan Administrator on an as needed basis. PRIOR AUTHORIZATION: The Plan requires that a Covered Person or Provider obtain prior authorization for the following Covered Services or procedures:

1. Outpatient surgery performed in a facility, except epidural injections

2. Home health care services

3. Hospice services

4. Skilled nursing facility services

5. Physical, speech, occupational therapy

6. MRI, MRA, CT scans, PET and SPECT scans

7. Sleep studies

8. Outpatient wound care

9. Cardiac catheterizations

10. Kidney dialysis

11. Chemotherapy and radiation therapy, including chemotherapy performed in a Physician’s office

12. Botox injections

13. Sclerotherapy

14. Durable medical equipment that costs over $500 per equipment

15. Air ambulance

Failure to obtain prior authorization to receiving the service or procedure will result in a loss of Coverage for the service or procedure.


DEDUCTIBLE: The Plan requires that a Covered Person pay Covered Charges each Plan Year in the amount of the Deductible before the Plan will pay Benefits for the Plan Year. For Plans A and B, there will be separate Inpatient Admission Deductibles for Inpatient Hospital, Inpatient Hospice and Inpatient Skilled Nursing Facility. This separate Deductible does not apply to Plan C.

The Deductible amounts for all Covered Services for all three (3) plan options are illustrated in the Schedule of Benefits.

CO-PAYMENTS: A Co-payment is the dollar amount that a Covered Person must pay for a specific Covered Service and is applied each time the Covered Person receives that Covered Service. The Co-payments for all Covered Services for all three (3) plan options are illustrated in the Schedule of Benefits. Co-payments shall not be used to satisfy the Deductible requirements except in Plan C, the Coinsurance requirements or the Out-Of-Pocket Maximum. COINSURANCE: The Plan will pay a percentage of the Provider’s allowable charge. This is referred to as Coinsurance. The Provider’s Allowable Charge is the Network Provider’s negotiated rate as established in the PPO contract. The Provider’s allowable charge for a Non-Network Provider is based on the Reasonable and Customary Charge. The Coinsurance amounts for all Covered Services for all three (3) plan options are illustrated in the Schedule of Benefits. The Coinsurance provision will apply to all Covered Charges unless explicitly modified in this Section.

OUT-OF-POCKET MAXIMUM: The Out-Of-Pocket Maximum shall consist of the Covered Person's Out-Of-Pocket expenses arising out of the Deductible and Coinsurance expenses for those Covered Expenses that are subject to Deductible and Coinsurance. The Out-Of-Pocket Maximum shall not include Co-payments. Once the Deductible and Coinsurance Out-Of-Pocket expenses for Covered Expenses reach the Out-Of-Pocket Maximum, the Plan will pay 100% of Covered Expenses for the remainder the Calendar Year, excluding Co-payments on plans other than the Consumer Driven Health Plan (CDHP). The Out-Of-Pocket Maximum for all Covered Services for all three plan options is illustrated in the Schedule of Benefits. Section 2. DEFINITIONS A) AMBULATORY SURGICAL CENTER. An Ambulatory Surgical Center means a place approved or

licensed as such by an agency of the governing jurisdiction. B) BENEFIT. A Benefit is the amount of Covered Expenses payable by the Plan pursuant to the terms and

provisions of the Plan. C) CERTIFICATE OF CREDITABLE COVERAGE. Under the Health Insurance Portability and Accountability

Act (HIPAA), group health plans are required to automatically provide Certificates of Creditable Coverage to all individuals, both employees and dependents who lose group health coverage on or after June 1, 1997. The Certificate of Creditable Coverage shows the type(s) of coverage and the length of time coverage was held. One would establish creditable coverage by presenting this Certificate of Creditable Coverage describing previous coverage. The Act (HIPAA) permits a lapse of coverage of sixty-three (63) days before prior coverage is no longer "creditable." Creditable Coverage will waive any Pre-existing Condition exclusion day for day by any period of Creditable Coverage.

The Plan Administrator automatically provides Certificates of Creditable Coverage to all individuals, both employees and dependents who lose group coverage under the Plan, and subsequently if COBRA is elected, at the end of the COBRA coverage period.

A request for Certificates of Creditable Coverage by or on behalf of a former employee or dependent must be honored as long as the request is received within twenty-four (24) months of when that individual lost coverage.

D) COSMETIC PROCEDURES. Cosmetic Procedures are the alterations of tissue (usually surgical) for the

improvement of appearance, but which is not intended to effect a substantial improvement or restoration of bodily function. These procedures are:


1) Due to neither injury nor illness; 2) Performed solely to improve the appearance rather than the function or usefulness of a structure of

the body. E) COVERAGE. Coverage means the benefits for a Covered Expense. Individual Coverage means the

Coverage for the Eligible Employee only. Family Coverage means the Coverage for the Eligible Employee and any Eligible Dependent(s).

F) COVERED EXPENSE. A Covered Expense is an expense expressly described as such in this Plan, and which: (i) if made by a Network Provider, is the Provider’s Allowable Charge; and (ii) if made by an Out-Of- Network Provider, is either a Reasonable and Customary Charge in the case of a Physician or supplier, or a charge calculated by the Plan Administrator that approximates the standard or usual charge made by a Network Provider in the case of a Health Care Provider that is not a Physician or supplier.

G) COVERED PERSON. An Eligible Employee or Eligible Dependent, who has elected Coverage in

accordance with the Plan and who has made any required contribution, if any, for coverage under the Plan. Covered Person is also sometimes referred to as Participant in this Summary Plan Description.

H) COVERED SERVICE. A Covered Service is a service or procedure that is considered a Covered Expense

and is considered eligible for payment under the Plan.

I) CUSTODIAL CARE. Care comprised of services and supplies provided primarily to assist in the activities of daily living.

J) DEDUCTIBLE. The amount of expenses a Covered Person must pay in each Plan Year before benefits

are payable under this Plan. In addition, for Plans A and B, there is a per admission Deductible for all Inpatient Hospital, Inpatient Hospice, Inpatient Skilled Nursing Facility.

K) DRUGS.

BRAND NAME. Brand Name Drugs shall mean prescription drugs, which are sold under a name, which is protected by a federally registered trademark. GENERIC. Generic Drugs shall mean prescription drugs, which are sold under a name not protected by a federally registered trademark and which are chemically equivalent to drugs sold under a name, which is protected by a federally registered trademark.

Drugs include insulin and prescription legend drugs. A legend drug is either:

1) A Federal Legend Drug, which is any medicinal substance which bears the legend: "Caution: Federal

Law prohibits dispensing without a prescription," or

2) A State Restricted Drug which is any medicinal substance which may be dispensed by prescription only, according to state law, and which is legally obtained from a licensed drug dispenser only upon a prescription of a currently licensed physician.

L) DURABLE MEDICAL EQUIPMENT. Durable Medical Equipment shall include equipment which:

1) Can withstand repeated use, and

2) Is primarily and customarily used to serve a medical purpose, and

3) Generally is not useful to a person in the absence of an illness or injury, and

4) Is appropriate for use in the home.

All requirements of the definition must be met before an item can be considered to be Durable Medical Equipment.


M) ELECTIVE SURGICAL PROCEDURE. An Elective Surgical Procedure is a non-emergency surgical procedure scheduled at the patient's convenience without jeopardizing the patient's life or causing serious impairment to the patient's bodily function.

N) ELIGIBLE DEPENDENT. An Eligible Dependent shall mean:

1) The spouse of an Eligible Employee (formal documentation in the form of a marriage or common-law certificate is required).

2) Your children up to age 26 who are not eligible to enroll in another employer-sponsored health plan.

a) Children are your natural or lawfully adopted children (including children placed for adoption),

stepchildren and persons for whom you are the legal guardian.

b) Children are eligible if they are covered under the terms of a court decree (a QMCSO).

c) Your children who are unable to support themselves because of a permanent mental or physical handicap and are dependent on you for support and maintenance, and are considered dependents for income tax purposes. These children must have been covered by the Plan prior to reaching age 26. You must provide proof of the child’s disability to the claims administrator within 31 days after his or her coverage would otherwise end. Thereafter, you must provide proof of the disability once per year.

d) Persons not meeting the above criteria are not eligible for coverage. For example – parents,

grandparents, and adult siblings.

e) If you acquire a dependent while you are eligible for coverage for dependents, coverage for the newly acquired dependent will be effective on the first day of the month following the date the dependent become eligible, provided you make written application for the dependent and agree to make any required contributions, within 31 days of the date of eligibility.

O) ELIGIBLE EMPLOYEE. An Eligible Employee is any full-time employee. Full-time employee shall mean

an employee retained by Employer to work a minimum of twenty (20) hours per week P) EMERGENCY CARE. Emergency Care means health care services provided in a Hospital emergency

facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the person's condition, illness, or injury is of such a nature that failure to get immediate medical care could result in:

1) Placing the patient's health in serious jeopardy;

2) Serious impairment to bodily functions;

3) Serious dysfunction of any bodily organ or part;

4) Serious disfigurement; or

5) In the case of a pregnant woman, serious jeopardy to the health of the fetus.

Q) EMERGENCY MEDICAL CONDITION. Means a medical condition manifesting itself by acute symptoms of

sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (i), (ii) or (iii) of section 18679(e)(1)(A) of the Social Security Act (42 U.S.C. 1395dd(e)(1)(A)). In that provision of the Social Security Act, clause (i) refers to placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; clause (ii) refers to serious impairment to bodily function; and clause (iii) refers to serious dysfunction of any bodily organ or part.

R) EMERGENCY SERVICES. Means, with respect to an emergency medical condition:


1) A medical screening examination (as required under section 1867 of the Social Security Act, 42 U.S.C. 1395dd) that is within the capability of the emergency department of a hospital, including ancillary service routinely available to the emergency department to evaluate such emergency medical condition, and

2) Such further medical examination and treatment, to the extent they are within the capabilities of the

staff and facilities available at the hospital, as are required under Section 1867 of the Social Security Act (42 U.S.C. 1395dd) to stabilize the patient.

S) EMPLOYER. The Employer is Ysleta Independent School District. T) EMPLOYEE CONTRIBUITON. Employees pay benefit contributions one month in advance. The

employee will be responsible for any unpaid contributions. U) ENROLLMENT. Enrollment is the election by an Eligible Employee for coverage under the Plan. When an

Eligible Employee acquires Eligible Dependents, the Eligible Employee shall have thirty-one (31) days to enroll these Eligible Dependents under the Plan.

If an Eligible Employee does not cover Eligible Dependents under the Plan within thirty-one (31) days of

their first becoming eligible, the Eligible Employee must wait until the open enrollments of the Plan to obtain coverage for these dependents unless there shall have occurred a Qualifying Event. Under such circumstances, the Eligible Employee will have thirty-one (31) days to elect coverage for those Eligible Dependents. If benefits are not elected at that time, the Eligible Employee must wait until the next open enrollment period of the Plan.

An Eligible Employee shall have the right, with respect to a child who is born while the Eligible Employee is

a Covered Person under the Plan, and where such Eligible Employee has previously waived coverage for other Eligible Dependent children, to obtain benefits for this child under the Plan. This child is a Covered Dependent under the Plan from the moment of birth.

However, any coverage that this child has solely by reason of this Newborn Child Provision, is hereby

modified to provide that no benefits will be payable for any charge incurred for a service or supply which is necessary for the covered medical care of this child after the end of the thirty-one (31) day period, which immediately follows the child's birth, unless the Eligible Employee notifies the Plan and completes any necessary enrollment forms during this same thirty-one (31) day period. In the event that an Eligible Employee has previously waived coverage for Eligible Dependents, this child who has become covered from the moment of birth by reason of Newborn Child Provisions will continue to be covered after the end of the thirty-one (31) day period if the Eligible Employee enrolls this newborn child during the thirty-one (31) day period which immediately follows the child's date of birth.

V) ESSENTIAL HEALTH BENEFITS. Shall mean, under section 13029b) of the Patient Protection and

Affordable Care Act, those health benefits to include at least the following general categories and the items and services covered within the categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness service and chronic disease management; and pediatric service, including oral and vision care.

W) EXPERIMENTAL OR INVESTIGATIONAL DRUG, DEVICE, TREATMENT OR PROCEDURE:

1) A drug or device, which cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and which has not been so approved for marketing at the time the drug or device is furnished; or

2) A drug, device, treatment or procedure, which was reviewed and approved (or which is required by

federal law to be reviewed and approved) by the treating facility's Institutional Review Board or other body serving a similar function, or a drug, device, treatment or procedure, which is used with a patient informed consent document, which was reviewed and approved (or which is required by federal law to be reviewed and approved) by the treating facility's Institutional Review Board or other body serving a similar function; or


3) A drug, device, treatment or procedure, which Reliable Evidence shows is the subject of on-going phase I, II or III clinical trials or is under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or

4) A drug, device, treatment or procedure for which the prevailing opinion among experts, as shown by

Reliable Evidence, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy as compared with a standard means of treatment or diagnosis.

Reliable Evidence means only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, treatment or procedure.

X) EXTENDED CARE FACILITY/SKILLED NURSING FACILITY. The term "Extended Care Facility" or "Skilled

Nursing Facility" means an institution (or a distinct part of an institution) which:

1) Provides for inpatients twenty-four (24) hours nursing care and related services for patients who require medical or nursing care, or service to the rehabilitation of injured or sick persons; and

2) Has policies developed with the advice of (and subject to review by) professional personnel to cover

nursing care and related services; and

3) Has a physician, a registered professional nurse, or a medical staff responsible for the execution of such policies; and

4) Requires that every patient be under the care of a physician, and makes a physician available to furnish

medical care in case of emergency; and

5) Maintains clinical records on all patients, and has appropriate methods for dispensing drugs and biologicals; and

6) Has at least one registered professional nurse on duty at all times; and

7) Provides for periodic review by a group of physicians to examine into the need for admissions, adequacy

of care, duration of stay and medical necessity of continuing confinement of patients; and

8) Is licensed pursuant to law, or is approved by appropriate authority as qualifying for licensing.

9) However, such term does not include a place, which is primarily for Custodial Care. Y) GINA - “GINA” shall mean the Genetic Information Nondiscrimination Act of 2008 (Public Law No. 110-233. “GINA” prohibits group health plans, issuers of individual health care policies, and employers from discriminating on the basis of genetic information. The term “genetic information” means, with respect to any individual, information about:

1. Such individual’s genetic tests; 2. The genetic tests of family members of such individual; and 3. The manifestation of a disease or disorder in family members of such individual.

The term “genetic information” includes participating in clinical research involving genetic services. Genetic tests would include analysis of human DNA, RNA, chromosomes, proteins, or metabolite that detect genotypes, mutations or chromosomal changes. Genetic information is a form of Protected Health Information (PHI) as defined by and in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and is subject to applicable Privacy and Security Standards. Family members as it relates to GINA include dependents, plus all relatives to the fourth degree, without regard to whether they are related by blood, marriage, or adoption. Underwriting as it relates to GINA


includes any rules for determining eligibility, computing premiums or contributions, and applying preexisting conditions. Offering reduced premiums or other rewards for providing genetic information would be impermissible underwriting. GINA will not prohibit a health care Provider who is treating an individual from requesting that the patient undergo genetic testing. The rules permit the Plan to obtain genetic test results and use them to make claims payment determinations when it is necessary to do so to determine whether the treatment provided to the patient was medically advisable and/or necessary. The Plan may request, but not require, genetic testing in certain very limited circumstances involving research, so long as the results are not used for underwriting, and then only with written notice to the individual that participation is voluntary and will not affect eligibility for benefits, premiums or contributions. In addition, the Plan will notify and describe its activity to the Health and Human Services secretary of its activities falling within this exception. While the Plan may collect genetic information after initial enrollment as authorized by law, it may not do so in connection with any annual renewal process where the collection of information affects subsequent enrollment. The Plan will not adjust premiums or increase group contributions based upon genetic information, request or require genetic testing or collect genetic information either prior to or in connection with enrollment or for underwriting purposes. Z) HEALTH CARE PROVIDER (or PROVIDER). A Health Care Provider is legally licensed in the United States

of America and provides medical care or diagnostic treatment to individuals for a covered illness or injury. The requirement that the Health Care Provider be legally licensed in the USA will be waived when treatment is provided to a Covered Person by a Health Care Provider licensed in the country where services are provided, in an emergency while traveling outside the United States. Examples, though not an exhaustive list, of Health Care Providers are as follows:

1) Ambulatory Surgical Center 2) Extended Care Facility 3) Home Health Agency 4) Hospice 5) Hospital 6) Laboratory

7) Nurse 8) Physician 9) Psychologist 10) Therapist 11) Master of Social Work 12) Licensed Clinical Social Worker

AA) HIPAA. HIPAA shall mean the following collectively:

1) The federal Health Insurance Portability and Accountability Act of 1986 (HIPAA) and regulations promulgated with respect thereto. This Act establishes federal standards for the availability and portability of group and individual health insurance coverage. The provisions of this Act affect coverage whether the coverage is provided through self-insured plans, group health insurance, through individual policies or by HMO. This Act is designed to provide more options for maintaining health insurance for individuals that change jobs, lose jobs, become self-employed, or move to a company that does not provide health insurance. This Act also limits the ability of employers or insurance issuers to impose Pre-existing condition exclusions or to use an individual's health status to deny coverage.

2) Chapter 181 of the Texas Health Code and Chapter 28B of the Texas Insurance Code (collectively, the

“Texas Health Privacy Standards”) and regulations promulgated with respect thereto. BB) HOME HEALTH AGENCY. A Home Health Agency means a public or private agency which:

1) Is certified as a Home Health Agency under Medicare or is licensed as a Home Health Agency by the state; and

2) Is primarily engaged in providing skilled nursing and other therapeutic services; and

3) Has its policies set by a professional group which governs the services provided; and

4) Maintains records for each patient.


CC) HOSPICE. Hospice means a public or private entity, which is licensed or certified as a Hospice by Medicare and by the State. The care provided by a Hospice means the palliative, supportive and related care for the person diagnosed as terminally ill with a medical prognosis that life expectancy is six (6) months or less; but only where the Hospice:

1) Provides care on a twenty-four (24) hour basis to include providing control of symptoms associated with

terminal illness; and 2) Has an interdisciplinary team consisting of:

3) at least one (1) Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.);

4) at least one (1) Registered Nurse (R.N.); and 5) at least one (1) volunteer and a volunteer program; and

6) Maintains central clinical records on all patients; and

7) Provides appropriate methods of dispensing and administering drugs and medicines; and

8) Is not an organization or part thereof which:

9) is primarily engaged in providing custodial care, care for drug addicts and alcoholics, or domestic

services; or

10) is a place for rest, a place for the aged, a hotel, or similar institution. DD) HOSPITAL. Hospital means an institution for care of the sick or injured, which is properly licensed to

operate as such, and which has licensed graduate registered nurses on duty twenty-four (24) hours a day, a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) on call at all times, and facilities for diagnosis of illness and related equipment for performing surgery. The requirement of surgical facilities shall not apply to a treatment center, which is duly licensed for, and specialized in, the care and treatment of those who are mentally ill. In no event will the term Hospital include an institution which:

1) Furnishes primarily domiciliary or custodial care; or

2) Furnishes training in the routines of daily living; or

3) Is operated primarily as a school.

For the treatment of chemical dependency, the term Hospital shall also include a Chemical Dependency Treatment Center. The term Chemical Dependency Treatment Center means a facility which provides a program for the treatment of alcohol and other chemical dependence pursuant to a written treatment plan approved and monitored by a physician and which facility is also:

1) Affiliated with a Hospital under the contractual agreement with an established system for patient referral,

or 2) Accredited as such a facility by the Joint Commission on Accreditation of Healthcare Organizations

(JCAHO or Joint Commission), or

3) Licensed as an Chemical Treatment Program by the Texas Commission on Alcohol and Drug Abuse (TCADA), or

4) Licensed, Certified, or Approved as a Chemical Dependency Treatment Program or Center by any other

State Agency having legal authority to so license, certify or approve. EE) HOSPITAL CONFINEMENT. A stay in a Hospital is considered a Hospital Confinement when a Covered

Person is admitted as an inpatient, and is charged room and board for at least twenty-four (24) hours.


FF) INCURRED EXPENSES. An expense is deemed to be incurred on the date a service is rendered or a supply is furnished.

GG) INJURY. Injury means an accidental bodily injury, which requires treatment by a physician. It must result

in loss independently of illness and other causes. HH) IN NETWORK. In Network shall mean treatment or services provided by Network Providers. II) LABORATORY. A Laboratory means a public or private entity which is equipped for scientific

experimentation, research, testing, or clinical studies of materials, fluids, or tissues obtained from patients and is properly approved or licensed as such by an agency of the governing jurisdiction.

JJ) LEAVE OF ABSENCE. Leave of Absence means a period of time during which the otherwise Eligible

Employee does not work but which is of stated duration; after which time, the otherwise Eligible Employee is expected to return to regular, active, full-time employment.

KK) MASTECTOMY. The Federal Federal Women’s Health and Cancer Rights Act, signed into law on October

21, 1998, contains coverage requirements for breast cancer patients who elect reconstruction in connection with a Mastectomy. The new Federal law requires group health plans that provide Mastectomy coverage to also cover breast reconstruction Surgery and prostheses following Mastectomy.

As required by law, you are being provided this notice to inform you about these provisions. The law mandates that individuals receiving benefits for a Medically Necessary Mastectomy will also receive coverage for:

1) Reconstruction of the breast on which the Mastectomy has been performed;

2) Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

3) Prostheses and physical complications from all stages of Mastectomy, including lymphedamas; in a

manner determined in consultation with the attending Physician and the patient.

This coverage will be subject to the same annual Deductible and coinsurance provisions that currently apply to Mastectomy coverage, and will be provided in consultation with you and your attending Physician.

LL) MEDICAL CASE MANAGEMENT PROGRAM. Medical Case Management Program shall mean a program,

which provides for a nurse case manager to coordinate the medical services required by a Covered Person in the event such Covered Person suffers a serious illness or Injury which involves ongoing care or Hospital Confinement. The nurse case manager shall explore with the Covered Person, such Covered Person's family and the treating Physician, the availability and feasibility of possible alternative treatment plans.

MM) MEDICALLY NECESSARY. Medically Necessary shall mean services, treatment, supplies or drugs ordered or authorized by a Physician and which is determined by the designated Utilization Review Organization to be:

1) Provided for the diagnosis or direct treatment of an injury or illness;

2) Appropriate and consistent with the symptoms and findings or diagnosis and treatment of the Covered Person’s injury or illness;

3) Provided in accordance with generally accepted medical practice on a national basis; and

4) The most appropriate supply or level of service which can be provided on a cost effective basis (including, but not limited to, inpatient versus outpatient care, electric versus manual wheelchair, surgical versus medical or other types of care).

The fact that the Covered Person’s Physician prescribes services or supplies does not automatically


mean such services or supplies are Medically Necessary and covered by the Plan. NN) MEDICALLY APPROPRIATE. Medically Appropriate shall mean:

1) Required for the symptoms and diagnosis associated with the medical or psychological illness, injury or surgical procedure of the Covered Person;

2) Provided in the facility, setting, or environment which can provide the most appropriate and cost effective

level of care for the Covered Person's medical or psychological illness, injury or surgical procedure; and

3) Determined in the discretion of each of the applicable Administrators specified below to be within acceptable standards of medical or psychological practice for the specific Covered Person’s medical or psychological illness, injury or surgical procedure.

a. The Utilization Review Organization for the Out of Area Plan and for treatment or services

provided by Out-Of-Network Providers under the Managed Care Plan;

b. The designated Utilization Review Organization for treatment or services provided by Network Providers under the Plan.

OO) MEDICARE. Medicare means the Part A and Part B plans described in Title XVIII of the United States

Social Security Act, as amended. PP) NAMED FIDUCIARY. The Named Fiduciary is the person who has the authority to control, manage the

operation and administration of the Plan. The Named Fiduciary for the Plan is Ysleta Independent School District.

QQ) NEGOTIATED RATE. Negotiated Rate shall mean the amount, which a Network Provider has agreed to

accept as payment in full for a specified treatment, service or supply provided to a Covered Person, pursuant to a contract between the applicable Network Provider and the Network PPO.

RR) NETWORK PPO. Network PPO shall mean the Plan’s managed care preferred provider organization

composed of Network Providers. SS) NETWORK ADMINISTRATOR. Network Administrator shall mean the person or entity appointed Network

Administrator.

TT) NETWORK PROVIDER. Network Provider shall mean a Health Care Provider who has contracted with the network indicated on the Identification Card to provide treatment or services to Covered Persons under the Plan and to accept Negotiated Rates as payment in full for such treatment and services.

UU) NON-NETWORK BENEFITS. Non-Network Benefits shall mean Benefits as defined in the Plan for services or supplies provided by Non-Network Providers.

VV) NON-NETWORK PROVIDER. Non-Network Provider shall mean a Health Care Provider who has not contracted with the Network PPO to provide treatment or services to Covered Persons under the Plan.

WW) NON-OCCUPATIONAL. Non-Occupational shall mean a condition which does not arise out of or in the

course of employment for pay or profit and does not qualify under any Workers' Compensation law or similar legislation.

XX) NURSE. A Nurse is a properly licensed person holding the degree of Registered Nurse (R.N.), Licensed

Vocational Nurse (L.V.N.), or Licensed Practical Nurse (L.P.N.). YY) OFFICE VISIT. Office Visit shall mean the following services provided by a Physician in his office or in an

Outpatient setting:

1) Time spent with or on behalf of the patient; 2) Reviewing of patient history;


3) Examination of the patient; 4) Diagnosis; 5) Medical decision-making; 6) Counseling; and 7) Coordination of medical care.

ZZ) OUTPATIENT. An Outpatient is a Covered Person who is treated at a Hospital and is confined less than 24

consecutive hours AAA) PHYSICIAN. A Physician is a person legally licensed in the United States of America holding the degree

of Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Dental Surgery (D.D.S.), Doctor of Chiropractic (D.C.), or Doctor of Optometry (O.D.).

BBB) PLAN. This Plan, which is the Ysleta Independent School District Health Benefits Fund and provides for

the Benefits and payment of Benefits as provided herein. This Plan is also the SPD.

CCC) PLAN ADMINISTRATOR. The Plan Administrator is the person or firm providing technical services and advice to the Employer in connection with the operation of the Plan and performing such other functions including processing any payment of claims as may be delegated to it. The Plan Administrator is Ysleta Independent School District, El Paso, Texas

DDD) PLAN SPONSOR. The Plan Sponsor is Ysleta Independent School District, El Paso, Texas. The Plan Sponsor, as used herein, shall be the person or firm responsible for the day to day function and management of the Plan and shall act as agent for service of legal process.

EEE) PLAN YEAR. The Plan year runs from January 1st through the following December 31st.

FFF) PPO BENEFITS. PPO Benefits shall mean the Benefits as defined in the Plan for treatment or services provided by Network Providers.

GGG) PRECERTIFICATION. Precertification is a procedure, completed in advance of obtaining services or

supplies, which justifies the Medical Necessity of specific types of care and services covered under this Plan. When utilizing an In Network Medical Care Provider, it is that Provider's responsibility to handle Precertification. The member is not penalized. When utilizing Out-Of-Network Health Care Providers, it is the responsibility of the Covered Person to handle Precertification. In order to pre-certify or check on Precertification, please contact HealthSCOPE Benefits at 915-581-8182.

HHH) PRE-EXISTING CONDITIONS EXCLUSION. Pre–existing Condition means a condition, regardless of its

cause, for which medical advice, diagnosis, care or treatment was received or recommended during a six (6) month period ending on the Enrollment Date (genetic information shall not be treated as a pre–existing condition in the absence of an actual diagnosis of the condition related to the genetic information). It does not mean the birth defects of a newborn child. Pre-existing condition limitation does not apply to any covered person who has not yet reached age 19. Enrollment Date means the first day of insurance, or if there is a waiting period, the first day of the waiting period, unless you are a late applicant as explained in the Effective Date of Insurance section. If you are a late applicant, Enrollment Date means the first day insurance begins. During the first 12 consecutive months following the Covered Person’s Enrollment Period, expenses due to a Pre–Existing Condition are covered only for a maximum of $1,000 of expenses. Once the Covered Person reaches the $1,000, (s)he must wait until the end of this twelve (12) month period before additional expenses will be paid. Please note: if the Covered Person is a late enrollee, (s)he must wait at additional period of time not to exceed eighteen (18) consecutive months beginning on the Covered Person’s Enrollment Date.

A Certificate of Creditable Coverage can eliminate or reduce the waiting period on Pre-existing Conditions.


III) PREFERRED LAB. Preferred Lab shall mean a designated laboratory entity that will offer the Plan maximum benefit in which contracted/negotiated fees are considered payment in full.

JJJ) PREGNANCY. Shall include resulting childbirth, except for complications arising from, as defined herein as

Pregnancy Complications. If, while covered under the Plan, a female employee Covered Person or a Covered Dependent wife or a Covered Dependant daughter becomes pregnant and on account of such pregnancy incurs any Covered Expense, the Plan shall pay such Covered Expense in the same manner as any other covered illness. Pre-existing conditions and extension of Benefits for pregnancy shall be covered in the same manner as any other covered illness. Pregnancy is considered to have commenced nine (9) months before its termination. Covered Dependent children are eligible for maternity care.

KKK) PREGNANCY COMPLICATIONS. Pregnancy Complications shall include the following:

1) Conditions requiring Hospital confinement (when the pregnancy is not terminated) whose diagnosis are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, Physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy, and

2) Non elective Caesarean section, ectopic pregnancy which is terminated and spontaneous termination

of pregnancy, which occurs during a period of gestation in which a viable birth is not possible, a miscarriage or a non elective abortion.

LLL) PRIMARY CARE PHYSICIAN. Primary Care Physician shall mean any physician who is licensed and

practices in one or more of the following professional areas:

1) Family Practice; 2) Internal Medicine; 3) Obstetrical and Gynecology; and

5) Pediatrics.

MMM) PROTECTED HEALTH INFORMATION (PHI). Health information that meets the following criteria:

1) information the plan creates or receives about a Covered Person

2) information relating to the Covered Person’s past, present, or future health condition or past, present, or future payment for health care services, and

3) information that either identifies the Covered Person or creates a basis upon which a disclosing entity

should believe that the information may be used to identify the Covered Person.

NNN) PROVIDER’S ALLOWABLE CHARGE. Provider’s Allowable Charge is the Network Provider’s negotiated rate as established in the PPO contract.

OOO) PSYCHOLOGIST. A Psychologist shall only include a practitioner who is duly licensed or certified in the state where the service is rendered and has a doctorate degree in psychology and has had at least two (2) years clinical experience in a recognized health setting, or has met the standards of the National Register of Health Service Providers in Psychology.

PPP) QUALIFYING EVENT and SPECIAL ENROLLMENT. The Plan is required to provide special enrollment

periods during which individuals who previously declined health coverage for themselves and their dependents may be allowed to enroll (regardless of any open enrollment period). Special enrollment rights can occur when one of the following Qualifying Events occur: An individual loses eligibility for coverage under a group health plan or other health insurance coverage (such as an employee and his/her dependents’ loss of coverage under the spouse’s plan) or when an employer terminates contributions toward health coverage; An individual becomes a new dependent through marriage, birth, adoption, or being


placed for adoption. The employee is responsible to enroll eligible dependents within 31 days of a Qualifying Event or a Special Enrollment. If the employee exceeds the 31 days, the employee will have to wait until the next annual open enrollment period.

QQQ) REASONABLE AND CUSTOMARY CHARGE. A Reasonable and Customary Charge shall be a charge

which is less than the usual charges made by a Physician or supplier of services, medicines, or supplies and shall not exceed the general level of charges made by others rendering or furnishing such services, medicines, or supplies within the area in which the charge is incurred for illness or injuries comparable in severity and nature to the illness or injury being treated..

The term "Area" as it would apply to any particular service, medicine, or supplies means such geographic area as is necessary to obtain a representative cross-section of the level of charges. The Plan Administrator shall make the determination of Reasonable and Customary Charge based on established criteria in determining available Benefits under the Plan.

RRR) SERIOUS MENTAL ILLNESS. Serious Mental Illness shall mean:

1) Schizophrenia;

2) Paranoid and other psychotic disorders;

3) Bipolar disorders (mixed, manic, and depressive);

4) Major depressive disorders (single episode or recurrent);

5) Schizo affective disorders (bipolar or depressive);

6) Pervasive developmental disorders;

7) Obsessive-compulsive disorders; and

8) Depression in childhood and adolescence

SSS) SERVICE AREA. Service Area shall mean the geographic area composed of United States Postal Service Zip Codes in which the Network Administrators have selected, established, and maintain a contracted network of Health Care Providers.

TTT) SPD. SPD shall mean this summary plan description. The SPD is also the Plan Document.

UUU) SPECIALIST. Specialist shall mean any Physician other than a Primary Care Physician. VVV) SURGICAL PROCEDURE. Surgical Procedure shall mean cutting, suturing, treating burns, correcting

fractures, reducing a dislocation, manipulating a joint under general anesthesia, electrocauterizing, tapping (paracentesis), applying plaster casts, administering pneumothorax, endoscopy or injecting sclerosing solution.

WWW) TERMINATION OF EMPLOYMENT. Termination of Employment shall mean termination of the

employee’s employment with the Employer, for any reason.

XXX) THERAPIST. A Therapist shall include a person who is duly licensed or certified in the state where the service is rendered to provide services for physical, speech or occupational therapy.

YYY) UTILIZATION REVIEW ORGANIZATION. A company chosen by the Plan Administrator to administer the

Health Care management provisions of the Plan, specifically, to conduct precertifications, continued care review, case management, and review of medical necessity.


Section 3. COMPREHENSIVE MEDICAL PLAN & PHARMACY SCHEDULE OF BENEFITS PLEASE NOTE: THERE ARE THREE (3) PLAN OPTIONS WHICH ARE DESCRIBED IN THIS SECTION. YOUR COVERAGE IS BASED ON THE OPTION, PLAN A, PLAN B OR PLAN C, WHICHEVER ONE YOU SELECTED AND IN WHICH YOU ARE CURRENTLY ENROLLED.

SCHEDULE OF BENEFITS MEDICAL BENEFITS

PLAN A Note: The Covered Person is entitled to Medical Benefits only if (s)he has made application for such

benefits and been enrolled for Coverage by the Plan Administrator under the Plan. COVERED SERVICE/PLAN CATEGORY

NETWORK PROVIDER BENEFITS NON-NETWORK PROVIDER BENEFITS

GENERAL INFORMATION Deductible (Per Calendar Year)

$200 per Individual Coverage $600 per Family Coverage

$400 per Individual Coverage $1,200 per Family Coverage

Deductible (Per Admission) $150 Deductible for all Inpatient Hospital, Inpatient Skilled Nursing

Facility and Inpatient Hospice admissions

$350 Deductible for all Inpatient Hospital, Inpatient Hospice, Inpatient Skilled Nursing Facility and Inpatient

Hospice admissions Coinsurance 80%

Except as specified 50%

Except as specified Out-Of-Pocket Maximum Includes Calendar Year Deductible & Coinsurance

$1,700 per Individual Coverage $5,100 per Family Coverage


COVERED SERVICES This listing of Covered Services appears in alphabetical order to better assist the Covered Person in locating the different benefit allowances for the specific Covered Services. All Covered Services listed below are subject to the Deductible (calendar year) unless specified otherwise in this Schedule of Benefits Allergy Testing, Treatment & Serum

80% after Deductible 50% after Deductible

Ambulance Services Patient must be transported Air ambulance requires prior authorization. Refer to Section 1.


Ambulatory Surgical Facility Services


Anesthesia Services 80% after Deductible 50% after Deductible

Cardiac Rehabilitation Therapy

80% after Deductible


Chemotherapy Requires prior authorization. Refer to Section 1.


Chiropractic Services $25 Copayment for manipulations Calendar Year Deductible and Coinsurance

does not apply to manipulations




for all other Covered Services $2,000 maximum benefit per Covered Person per calendar year

Cosmetic Services Only (Medically Necessary Reconstructive Surgery)


Diabetic Education Services 80% after Deductible 50% after Deductible Diagnostic Tests Certain diagnostic tests require prior authorization. Refer to Section 1.


Dialysis Requires prior authorization. Refer to Section 1.


Durable Medical Equipment Durable Medical Equipment over $500 requires prior authorization. Refer to Section 1.


Emergency Care in Emergency Department of Hospital

$100 Copayment, then 80% after Deductible

Copayment applies to Hospital charges only

and is waived if Covered Person is admitted to the Hospital




80% after Deductible 50% after Deductible Home Health Care Services Requires prior authorization. Refer to Section 1.

Subject to a maximum benefit of sixty (60) visits per Calendar Year.

Inpatient: $150 Deductible per admission, then 80% after Deductible

Outpatient: 80% after Deductible



Hospice Services Requires prior authorization. Refer to Section 1. Inpatient & Outpatient hospice services

Respite care and bereavement counseling not covered $150 Deductible per admission,

then 80% after Deductible

$350 Deductible per admission,


Hospital Confinement All Hospital admissions are subject to Pre-certification. Refer to Section 1.

The per admission Deductible applies to all Hospital admissions.

Medical and Surgical Supplies


80% after Deductible 50% after Deductible Morbid Obesity Surgical Procedures

Refer to benefit description for conditions and limitations

80% after Deductible 50% after Deductible Obstetrical Services • All covered females eligible • Initial office visit (to confirm pregnancy) covered under Office Visit

(Non-Routine) benefit. All remaining pre and post-natal office visits billed as part of delivery expenses.


• Two (2) ultrasounds covered for uncomplicated pregnancy, no limit for complicated pregnancy

• Infant’s charges are paid under mother’s confinement, as long as mother and infant are discharged on the same day

Occupational Therapy Services Requires prior authorization. Refer to Section 1.


80% after Deductible 50% after Deductible Orthotic Devices Must be prescribed by a Network Provider

Physical Therapy Services Requires prior authorization. Refer to Section 1.


Physician Office Visits (Non-Routine Care)

PCP: $15 Copayment per office visit Specialist: $25 Copayment per office

visit Calendar Year Deductible and Coinsurance do not apply to PCP/Specialist office visit charges

All services other than office visit

charge subject to 80% after Deductible


Physician Inpatient Visits (Hospital & Skilled Nursing Facility Confinement)


Preventative Care for Dependent Children (Age 2 and Older) and Adults

Office Visit: $15 Copayment for exam per office visit

Calendar Year Deductible and Coinsurance do not apply to PCP/Specialist office visit charges

All other services subject to



Preventative Care for Covered Dependent Children (to Age 2)






Prosthetic Appliances 80% after Deductible 50% after Deductible

Psychiatric Services (Outpatient)

PCP Psychotherapy: $15 Copayment per treatment

Specialist Psychotherapy: $25 Copayment per treatment

Calendar Year Deductible and Coinsurance do not apply to PCP/Specialist psychotherapy

charges

All other psychiatric services subject to 80% after Deductible


Radiation Therapy Requires prior authorization. Refer to Section 1.



Respiratory Therapy 80% after Deductible 50% after Deductible





Skilled Nursing Facility Services Requires prior authorization. Refer to Section 1.

• Sixty (60) days per Covered Person per benefit period

Speech Therapy Requires prior authorization. Refer to Section 1.


Substance Abuse Services (Outpatient)

Psychotherapy: $25 Copayment per treatment

Calendar Year Deductible and Coinsurance do not apply to PCP/Specialist psychotherapy

charges

All other substance abuse services subject to 80% after Deductible


80% after Deductible 50% after Deductible Surgical Services Outpatient surgery requires prior authorization. Refer to Section 1.

• Surgical assistant: 20% of primary surgeon’s allowed amount • Multiple surgeries: 100% of allowed amount for 1st surgery; 50% of

allowed amount for 2nd surgery; and 50% of allowed amount for 3rd and subsequent surgeries

Transplant Surgical Procedures


Urgent Care Services in Urgent Care Facility



Wellness/Gym Benefit-Health 15

All Covered Persons are eligible to participate and will receive $15 monthly reimbursement if the following conditions are satisfied:

• Performance of an assessment through a Life Care Center • The completion of an application for reimbursement. Copies may be

obtained from the Employer or by going to www.healthscopebenefits.com

• The Covered Person must attend eight (8) sessions per month for six (6) consecutive months.

• The Covered Person must provide proof of payment and proof that (s)he has completed all of the required sessions.

Certain Covered Services are subject to Pre-Certification and Prior Authorization. Failure to obtain Pre-Certification and/or Prior Authorization will result in a penalty. Refer to Section 1 for details.




PLAN B Note: The Covered Person is entitled to Medical Benefits only if (s)he has made application for such

benefits and been enrolled for Coverage by the Plan Administrator under the Plan. COVERED SERVICE/PLAN

CATEGORY NETWORK PROVIDER BENEFITS NON-NETWORK PROVIDER

BENEFITS


$750 per Individual Coverage $2,250 per Family Coverage


Deductible (Per Admission)

$150 Deductible for all Inpatient Hospital, Inpatient Hospice, Inpatient

Skilled Nursing Facility, Inpatient Hospice admissions

$350 Deductible for all Inpatient Hospital, Inpatient Hospice, Inpatient

Skilled Nursing Facility, Inpatient Hospice and admissions

Coinsurance 80% Except as specified

50% Except as specified

Out-Of-Pocket Maximum Includes Calendar Year Deductible & Coinsurance



COVERED SERVICES

This listing of Covered Services appears in alphabetical order to better assist the Covered Person in locating the different benefit allowances for the specific Covered Services.

All Covered Services listed below are subject to the Deductible (calendar year) unless specified otherwise in this Schedule of Benefits

Allergy Testing, Treatment & Serum






Anesthesia Services 80% after Deductible 50% after Deductible Cardiac Rehabilitation Therapy




$35 Copayment for manipulations Calendar Year Deductible and Coinsurance do not

apply to manipulations

80% after Deductible for all other Covered Services

50% after Deductible Chiropractic Services

$2,000 maximum benefit per Covered Person per calendar year Cosmetic Services Only (Medically Necessary Reconstructive Surgery)


Diabetic Education Services



Diagnostic Tests Certain diagnostic tests require prior authorization. Refer to Section 1.








Copayment applies to Hospital charges only and is

waived if Covered Person is admitted to the Hospital




80% after Deductible 50% after Deductible Home Health Care Services Requires prior authorization. Refer to Section 1.






Hospice Services Requires prior authorization. Refer to Section 1. Inpatient & Outpatient hospice services

Respite care and bereavement counseling not covered $150 Deductible per admission,





The per admission Deductible applies to all Hospital admissions. Medical and Surgical Supplies


80% after Deductible 50% after Deductible Morbid Obesity Surgical Procedures

Refer to benefit description for conditions and limitations 80% after Deductible 50% after Deductible Obstetrical Services

• All covered females eligible • Initial office visit (to confirm pregnancy) covered under Office Visit (Non-

Routine) benefit. All remaining pre and post-natal office visits billed as part of delivery expenses.





Orthotic Devices 80% after Deductible 50% after Deductible


Must be prescribed by a Network Provider Physical Therapy Services Requires prior authorization. Refer to Section 1.



PCP: $25 Copayment per office visit Specialist: $35 Copayment per office visit

Calendar Year Deductible and Coinsurance do apply to PCP/Specialist office visit charges

All services other than office visit charge

subject to 80% after Deductible













All other services subject to 100% after Deductible


Prosthetic Appliances 80% after Deductible 50% after Deductible Psychiatric Services (Outpatient)


Calendar Year Deductible and Coinsurance do not apply to PCP/Specialist psychotherapy charges

All other psychiatric services subject to







then 80%after Deductible



Skilled Nursing Facility Services Requires prior authorization. Refer to Section 1. • Sixty (60) days per Covered Person per benefit period





Calendar Year Deductible and Coinsurance do not apply to PCP/Specialist psychotherapy charges



All other substance abuse services subject to 80%

80% after Deductible 50% after Deductible Surgical Services Outpatient surgery requires prior authorization. Refer to Section 1.

• Surgical assistant: 20% of primary surgeon’s allowed amount • Multiple surgeries: 100% of allowed amount for 1st surgery; 50% of

allowed amount for 2nd surgery; and 50% of allowed amount for 3rd and subsequent surgeries



Urgent Care Services in Urgent Care Facility




All Covered Persons are eligible to participate and will receive $15 monthly reimbursement if the following conditions are satisfied:

• Performance of an assessment through a Life Care Center • The completion of an application for reimbursement. Copies may be

obtained from the Employer or by going to www.healthscopebenefits.com • The Covered Person must attend eight (8) sessions per month for six (6)

consecutive months. • The Covered Person must provide proof of payment and proof that (s)he

has completed all of the required sessions. Certain Covered Services are subject to Pre-Certification and Prior Authorization. Failure to obtain Pre-

Certification and/or Prior Authorization will result in a penalty. Refer to Section 1 for details.


PLAN C Note: The Covered Person is entitled to Medical Benefits only if (s)he has made application for such

benefits and been enrolled for Coverage by the Plan Administrator under the Plan. COVERED SERVICE/PLAN

CATEGORY NETWORK PROVIDER BENEFITS NON-NETWORK PROVIDER

BENEFITS




Coinsurance 100% Except as specified

Covered Person has no Coinsurance

50% Except as specified

Out-Of-Pocket Maximum Includes Calendar Year Deductible & Coinsurance


No Limit Covered Person Must Continue to Pay

Coinsurance Throughout Calendar Year

COVERED SERVICES This listing of Covered Services appears in alphabetical order to better assist the Covered Person in locating the

different benefit allowances for the specific Covered Services. All Covered Services listed below are subject to the Deductible (calendar year) unless specified otherwise

in this Schedule of Benefits Allergy Testing, Treatment & Serum








Anesthesia Services 100% after Deductible 50% after Deductible Cardiac Rehabilitation Therapy





100% after Deductible 50% after Deductible Chiropractic Services $2,000 maximum benefit per Covered Person per calendar year

Cosmetic Services Only (Medically Necessary Reconstructive Surgery)

100% Deductible 50% after Deductible

Diabetic Education Services


Diagnostic Tests Certain diagnostic tests require prior authorization. Refer to Section 1.








Home Health Care Services Requires prior authorization. Refer to Section 1.


Hospice Services Requires prior authorization. Refer to Section 1.





Inpatient & Outpatient hospice services Respite care and bereavement

counseling not covered


50% after Deductible Medical and Surgical Supplies

The per admission Deductible applies to all Hospital admissions


50% after Deductible Morbid Obesity Surgical Procedures


Obstetrical Services

Refer to benefit description for conditions and limitations





• All covered females eligible • Initial office visit (to confirm

pregnancy) covered under Office Visit (Non-Routine) benefit. All remaining pre and post-natal office visits billed as part of delivery expenses.





Orthotic Devices 100% after Deductible 50% after Deductible Physical Therapy Services Requires prior authorization. Refer to Section 1.

Must be prescribed by a Network Provider









$25 Copayment for exam per office visit

Deductible waived



$25 Copayment for exam per office visit

Deductible waived


Prosthetic Appliances 100% after Deductible 50% after Deductible

Psychiatric Services (Outpatient)





Skilled Nursing Facility Services Requires prior authorization. Refer to Section 1.

100% after Deductible • Sixty (60) days per Covered

Person per benefit period








Surgical Services Outpatient surgery requires prior authorization. Refer to Section 1.



• Surgical assistant: 20% of primary surgeon’s allowed amount

• Multiple surgeries: 100% of allowed amount for 1st surgery; 50% of allowed amount for 2nd surgery; and 50% of allowed amount for 3rd and subsequent surgeries


50% after Deductible Urgent Care Services in Urgent Care Facility



All Covered Persons are eligible to participate and will receive $15 monthly

reimbursement if the following conditions are satisfied:

• Performance of an assessment

through a Life Care Center • The completion of an application

for reimbursement. Copies may be obtained from the Employer or by going to www.healthscopebenefits.com

• The Covered Person must attend eight (8) sessions per month for six (6) consecutive months.

• The Covered Person must provide proof of payment and proof that (s)he has completed all of the required sessions.

Certain Covered Services are subject to Pre-

Certification and Prior Authorization. Failure to obtain Pre-Certification

and/or Prior Authorization will result in a penalty. Refer to Section 1 for

details.



SCHEDULE OF BENEFITS PHARMACY BENEFITS

PLAN A, B AND C Retail Pharmacy

Participating

Retail Pharmacy Non-Participating

Mail Order Pharmacy

Generic Drug $15 Copayment Plan pays 65% after Medical Deductible

$30 Copayment

Preferred Brand Name Drug

$30 Copayment

Plan pays 65% after Medical Deductible

$60 Copayment

Non-Preferred Brand Name Drug

$50 Copayment Plan pays 65% after Medical Deductible

$100 Copayment

Preferred Brand or Non-Preferred Brand Name Drug Purchased When Generic Available

Covered Person pays the difference

between the Brand and Generic price

plus the Copayment

Covered Person pays the difference between the

Brand and Generic price plus the Copayment

Covered Person pays the difference between the

Brand and Generic price plus the Copayment

General Condition (for Plan C Only)

• Copayments shown in the Schedule of Benefits apply ONLY to prescription drugs for chronic conditions. Copayment applies until the Medical Deductible is satisfied (see the Schedule of Benefits for Medical Benefits), after which Plan pays 100% of remaining prescription drug expenses

• For all other prescription drugs, Plan pays 100% of the prescription drug expense once the Medical Deductible is satisfied (see the Schedule of Benefits for Medical Benefits)

Pharmacy Deductible (for Plan B Only) $100 Deductible

Please Note: On Plan C, under the family Coverage, one member must meet $2,400 of the family deductible and the rest of the family would accumulate the remaining $1,600 of the family deductible to arrive at the $4,000 family deductible/out of pocket max.


Section 4. MEDICAL AND PHARMACY EXPENSES COVERED MEDICAL EXPENSE. A Covered Expense shall mean a service or supply which is provided to a Covered Person, and which service or supply is: A) Received while a person is covered under the Plan; and B) Recommended by a physician; and C) Medically necessary for the care and treatment of a covered illness or injury of a covered person; and D) Provided by a Health Care Provider of these services or supplies. These services and supplies which are furnished by, and fall within the scope of the authorized practice of, a Health Care Provider must be recognized throughout the Health Care Provider's profession to be the usual and customary treatment for the illness or injury, provided that: A) Hospital Services: For a Hospital, Covered Expenses shall include the charges made by a Hospital, on its

own behalf, for room and board and other Medically necessary services and supplies, PROVIDED HOWEVER, that notwithstanding the foregoing, Covered Expenses shall not include: 1) any Hospital charges with respect to any day of Hospital Confinement with respect to a Hospital

admission commencing prior to the Covered Person’s enrollment date in the Plan; 2) any Hospital charges for room and board which are in excess of the Hospital’s average daily charge for

a semi private room or contracted network reimbursement formula (this limit shall not apply for a unit for intensive or specialized care); and

3) any Hospital charges for special nursing or Physician’s services.

B) Physician Services: For a Physician, services include:

1) Physician services while the Covered Person is in the Hospital. 2) Physician office visits for treatment or diagnosis purposes. 3) Physician office visits for Preventive Medicine services. Refer to the description for Preventive Medicine

services. 4) Physician services for Surgical Treatment. 5) Physician services for the routine delivery of an infant or the performance of a Caesarean section.

a) Covered Expenses shall include the stand-by services for a Pediatrician for a Caesarean section. b) Obstetrical services will be covered for all female Covered Persons. c) The initial office visit to confirm the pregnancy will be treated the same as any other non-routine

office visit and will not be considered as part of the obstetrical charges. d) All remaining pre- and post-natal office visits will be considered as part of the Physician’s

obstetrical charges. e) The Benefit will include two ultrasounds for a routine, uncomplicated pregnancy, with additional

ultrasounds being allowed for a complicated pregnancy. f) The newborn infant’s charges will be covered as part of the mother’s maternity confinement, as

long as both the mother and infant are discharged on the same day.


C) Nursing Services: Charges for services of a nurse shall include:

1) In a Hospital, services of a registered professional nurse (R.N.), services of a licensed practical nurse (L.P.N.), or services of a licensed vocational nurse (L.V.N.), and

2) Other than in a Hospital, services of a registered professional nurse (R.N.). Services of an L.V.N. or

L.P.N. are covered if it can be shown that no R.N. was available. 3) The services of a nurse shall not be considered eligible if they are rendered by a member of the

Covered Person's family as defined in the General Limitations Section.

D) Ambulance Services: For a Professional Licensed Ambulance Service, charges will include the services and supplies provided by the Professional Licensed Ambulance Service during:

1) Ground transportation by the Professional Licensed Ambulance Service to the nearest Hospital

qualified to render necessary medical treatment; or 2) Air ambulance transportation where it is medically necessary to air transport a Covered Person to the

nearest facility qualified to render treatment, or where a life threatening situation necessitates. E) Extended Care/Skilled Nursing Facility Services: For the charges for services and supplies provided by

a Licensed Extended Care Facility or Licensed Skilled Nursing Facility as listed below, the confinement begins by means of direct transfer from a Hospital. The following are covered Extended Care Facility or Skilled Nursing Facility services and supplies:

1) Board and room and nursing care (but no private duty nurse or attendant); 2) Physical therapy, occupational therapy and speech therapy; 3) Medical social service; 4) Biologicals, supplies, appliances, and equipment ordinarily provided by the facility for care of patients; 5) Medical care and other diagnostic and therapeutic services furnished to an Extended Care Facility or

Skilled Nursing Facility patient by a Hospital. F) Home Health Agency Services: For the charges for a Home Health Agency, provided that the plan of

care by the Home Health Agency:

1) Is prescribed by a Physician; and 2) Is reviewed and approved by the Physician every two weeks; and 3) Contains a statement expressing the belief of the Physician and the Home Health Agency that:

a) The number of days of home health care does not exceed the number of days of confinement in a

Hospital which would have been required; and b) The Home Health Care will probably cost less per day than the expected daily rate for

confinement in a Hospital; and c) Confinement in a Hospital would otherwise be required.

4) Is submitted for approval by the Plan prior to initiation of these services and supplies by the Home Health Agency. Home Health Care shall include:

a) Skilled Nursing Care; and

b) Any other services and supplies provided by the Home Health Agency in lieu of the services and

supplies, which would have been covered, if the Covered Person was confined in a Hospital. Home Health Care does not include housekeeping or custodial care.


G) Hospice Services: Covered Expense includes charges for Hospice care made by a Hospice only if:

1) The expenses incurred by a Covered Person diagnosed by a Physician as terminally ill with a prognosis of six (6) months or less to live; and

2) The Hospice provides a Plan of Care which:

a) Is prescribed by the Physician; and b) Is reviewed and approved by the Physician monthly; and c) Is not for curative treatment; and d) States the belief of the Physician and the Hospice that the Hospice Care will cost less in total

than any comparable alternative to Hospice Care; and e) Is submitted for approval by the Plan prior to initiation of this Hospice Care.

Hospice Care may be provided in a Covered Person's home or in a Hospice In-patient facility. For such Hospice Care, the Plan will not apply the requirement that expenses will be covered only when incurred for the treatment of an illness or injury.

H) Preventive Care for Dependent Children to Age Two (2). Preventive medicine services for dependent

children through twenty-four (24) months. Covered Services include:

1) Routine physical examination; 2) Routine lab work; 3) Routine immunizations; 4) Routine vision examinations

I) Preventive Care for Covered Persons Over Age Two (2). Preventive medicine services for all Covered

Persons age two (2) or older are covered at 100%. Covered Services include:

1) One (1) routine physical examination per year 2) One (1) routine colon/rectal cancer screening per Benefit Period 3) One (1) routine colonoscopy per Benefit Period 4) One (1) routine ovarian cancer screening per Benefit Period 5) One (1) routine prostate cancer screening (PSA) per Benefit Period 6) One (1) routine pap smear per Benefit Period 7) One (1) routine mammogram screening per Benefit Period 8) One (1) routine gynecological examination per Benefit Period (combined with routine physical

examination) 9) One (1) routine bone density scan per Benefit Period 10) Routine immunizations 11) Routine vision examinations through age five (5)


J) Additional Covered Expenses:

1) Charges made for anesthesia and its administration; and 2) Charges made for diagnostic X-ray and laboratory examinations; and 3) Charges made for X-ray, radium and radioactive isotope treatment; and 4) Charges for radiation therapy and chemotherapy; and 5) Charges for inhalation therapy; 6) Charges for occupational therapy; and 7) Cardiac rehabilitation therapy; and 8) Charges for chiropractic services (manipulation of the spine); and 9) Charges for psychiatric (mental health) and substance abuse services. Covered Services include

psychotherapy. In addition, mental health Covered Services include biofeedback, milieu therapy, treatment for behavioral disorders, developmental delay, autism and ADD/ADHA; and

10) Charges for: (a) correction of congenital abnormalities of the jaw; (b) excision of lesions; (c) incision of

accessory sinus, mouth, salivary glands or ducts; (d) surgical removal of all impacted teeth; and 11) Charges for diabetic education services; and 12) Charges for kidney dialysis; and 13) Charges made for blood transfusions; and 14) Charges made for oxygen and other gases and their administration; and 15) Charges made for prosthetic appliances; and 16) Charges for medical and surgical supplies; and 17) Charges for orthotics (back, knee, neck, wrist) and foot orthotics and orthopedic shoes. Foot orthotics

and orthopedic shoes must be prescribed by a Network Provider to be eligible for Coverage; and 18) Charges made for the rental or purchase of Durable Medical Equipment. The Physician's prescription

for the Durable Medical Equipment must be submitted to the Plan Administrator, by the Covered Person, to allow the Plan Administrator to determine whether to rent or purchase this necessary Durable Medical Equipment; and

PLEASE NOTE: Repairs for wear and tear due to normal use of equipment are subject to approval by the Plan Administrator. It is the Administrator’s discretion what constitutes “normal wear and tear.”

19) Charges for reconstructive surgery for:

a) The correction of a congenital deformity visible at birth b) Reconstructive surgery for treatment of an accidental injury to restore bodily function c) Breast reconstruction following a mastectomy, including reconstruction of the other breast to

create symmetrical appearance; and

20) Charges for sterilization procedures and supplies; and 21) Charges for Morbid Obesity (surgical procedure)


a) The Plan may pay for one (1) morbid obesity surgery per lifetime; b) Benefits for morbid obesity surgery will not be approved if the Covered Person has previously had

any type of obesity surgery; c) The Covered Person must be a minimum of 100 pounds over ideal weight or have a Body Mass

Index (BMI) equal to or greater than forty (40); d) Within one (1) year of the initial evaluation for the proposed surgical treatment of morbid obesity,

the Covered Person must complete a six (6) month medically monitored weight reduction program under the supervision of a physician, dietician/nutritionist, mental health provider or physiologist; and

e) The Covered Person must show evidence satisfactory to the Plan, in its reasonable discretion,

that the Covered Person has completed a medically monitored weight reduction program and despite completion of the program did not have success in weight loss

PLEASE NOTE: The intent is for surgical treatment of morbid obesity to be a last resort for the Covered Person. The member must show evidence that they have completed a medically monitored weight reduction program and despite completion of the program did not have success in weight loss. There will be no benefits available whether medically necessary or not for any surgical intervention for removal of excess skin post surgical treatment of morbid obesity or as a result of any other weight loss procedure; and

22) Charges for organ/tissue transplant procedures (surgical procedures under the following conditions):

a) Covered procedures includes: artery or vein; bone marrow; cornea; heart; heart/lung; kidney;

kidney/pancreas; liver; lung, single; pancreas; prosthetic lenses in connection with cataract surgery; prosthetic bypass or replacement vessels; and stem cell transfer.

b) The transplant procedure must not be experimental or investigational in nature; c) Donated human organs or tissue must be used; and d) The recipient must be a Covered Person under the Plan e) If the donor and recipient are both Covered Persons under the Plan, donor charges will be paid

under the donor’s Coverage f) If the donor is a Covered Person and the recipient is not, donor charges will not be covered.

COVERED PHARMACY EXPENSES A Covered Expense shall mean a prescription drug lawfully obtained from a retail pharmacy or mail order pharmacy upon the written prescription of a physician. The prescription drug must be:

1) Dispensed while a person is covered under the Plan; and 2) Prescribed by a physician; and 3) Medically necessary for the care and treatment of a covered illness or injury of a covered person; and 4) Filled by a licensed retail pharmacy or mail order pharmacy.

For non-maintenance prescription drugs obtained from a retail pharmacy, there is a Coverage limit of thirty (30) days for each supply of a non-maintenance drugs obtained. For maintenance drugs obtained upon written prescription of a physician, there is a Coverage limit of ninety (90) days for each maintenance supply obtained. Refer to the Schedule of Benefits for the Coverage limitations in connection with prescription drugs.


Section 5. GENERAL LIMITATIONS AND EXCLUSIONS

No payment will be made under this Plan for expenses incurred by an employee or a dependent. EXCLUDED EXPENSES. The term Excluded Expenses shall include any expense for a service or supply which is provided by someone other than a Health Care Provider or an expense provided by a Health Care Provider who does not meet the definition of Covered Expense. The term Excluded Expenses shall also include expenses for a service or supply which is provided by a Health Care Provider for any of the following:

A) Reconstructive surgery expenses are covered in only the following three circumstances:

1) due to an accidental injury;

2) for repair of congenital defects of newborn children, or for breast reconstruction following a total or

partial mastectomy, or

3) for breast reconstruction following a total or partial mastectomy, as follows:

a) reconstruction of the breast on which the mastectomy has been performed;

b) surgery and reconstruction of the other breast to produce a symmetrical appearance;

c) prosthesis and treatment of physical complications of all stages of mastectomy, including lymphedemas.

B) For eyeglasses or hearing aids; C) For the prevention or correction of teeth irregularities and malocclusion of jaws by wire appliances,

braces, or other mechanical aids, or any other care, repair, removal, replacement or treatment of teeth, or surrounding tissues, except:

1) When necessitated by damage to sound natural teeth or surrounding tissues as a result of an injury

which occurs while the employee or dependent, as the case may be, is covered under this Plan, or 2) For excision of impacted un-erupted teeth or of a tumor or cyst, or incision and drainage of an

abscess or cyst, or 3) For any other oral surgical procedure not involving any tooth structure, alveolar process, or gingival

tissues, or 4) For correction of a birth defect of a child.

D) Expenses for any condition or disability sustained while engaged in an activity primarily for wage, profit or

gain, that could entitle the Covered Person to a benefit under Workers' Compensation or similar legislation, whether or not enrolled, if eligible;

E) In a Hospital owned or operated by the United States Government; unless for services and supplies

obtained in accordance with the laws and regulations of the government and only to the extent that charges are made and the patient is legally required to pay;

F) To the extent that payment under this Plan is prohibited by any law of the jurisdiction in which the

employee or dependent resides at the time the expenses are incurred; G) For charges, which the Covered Person is not legally required to pay, or for charges which would not

have been made if no coverage had existed; H) For charges that are not Medically Necessary or Medically Appropriate; I) For general health examinations except as shown in the Section titled Medical Expenses

Covered/Excluded;


J) For orthoptics or visual training; K) For fitting or cost of eye glasses, contact lenses or hearing aids; L) For Dental expenses except as shown in the Section titled Medical Expenses Covered/Excluded; M) For expenses relating to cosmetic repairs except as shown in the Section titled Medical Expenses

Covered/Excluded; N) For transportation or travel other than as shown in the Section titled Medical Expenses

Covered/Excluded; O) For injury or illness resulting from war; P) For injury resulting from the commission or an attempt to commit a felony while under the influence or

injury resulting from the commission or an attempt to commit a felony. Q) For preventive medicine except as shown in the Section titled Medical Expenses Covered/Excluded; R) For Custodial Care while confined in a Hospital, extended care facility, or nursing home; S) For charges for routine foot care; T) For non-prescription drugs; U) For services rendered to any individual who requires them by reason of acting as a donor of any organ or

element of their body, unless the recipient of this organ or element is a Covered Person under the Plan; V) For acquisition of records; W) For charges for refractive surgeries and services; X) Excepting only surgical treatment of morbid obesity (e.g., Gastric Bypass, etc.) expressly permitted as

Covered Expenses after precertification, for obesity charges in connection with treatments, procedures, or inpatient Hospital drugs for obesity, weight reduction or dietetic control;

Y) For treatment by hypnosis, except as part of the physician's treatment of a mental illness or when

hypnosis is used in lieu of an anesthetic; Z) For services rendered on an experimental or research basis or not a recognized, generally accepted

medical practice; AA) For services rendered by a member of the Covered Person's family to include grandparents, parents,

brothers and sisters, cousins, aunts and uncles, nieces and nephews or similar in-laws related by marriage to the Covered Person;

BB) For any charges for diagnosed or treatment of infertility, including, but not limited to:

1) Fertility tests; 2) Direct attempts to cause pregnancy by hormone therapy, artificial insemination, in vitro fertilization,

and embryo transfer; CC) For reversal of sterilization procedures or surgery; DD) For charges for vocational therapy; EE) For the services and supplies for appliances or restorations used solely to increase vertical dimension,

reconstruct occlusion or correct or treat temporomandibular joint dysfunction or TMJ pain syndromes, or


FF) For charges not submitted as provided in this Plan to the Plan Administrator within March 31st of Plan year following the date such charges were incurred, a Covered person received the services or supplies, such claims not to be considered for payment.

GG) For services and supplies not specifically listed as a covered expense; HH) For private duty nursing services in a Hospital setting; II) For massage therapy services; JJ) For remediation therapy services; KK) For B-12 medication except when used for Pernicious Anemia or Krohn's Disease; LL) For any sex change surgery; MM) For any city or state taxes charged for services and supplies; NN) For rolfing services; OO) For services and supplies not related to the diagnosed illness or injury, which is being treated; PP) For chelation therapy services and/or supplies. QQ) For charges made in excess of the Reasonable and Customary allowable as determined by the Plan

Administrator for Out-Of-Network or Out of area Hospital services and charges in excess of the Provider’s Allowable Charge for all Network Provider services.

RR) Charges incurred for services and supplies for medical care under the Plan to the extent payment is

made by an individual or individuals (or their insurers) considered responsible for the condition causing the charges.

SS) For a Hospital admission for diagnostic or evaluation procedures unless the tests could not have been

performed on an outpatient basis without adversely affecting the patient's physical condition or the quality of medical care rendered;

TT) For broken appointments or for charges for completion of claim form by the Physician's office; UU) For assistant surgeon fees in excess of 20% of the Reasonable and Customary Charge or Provider’s

Allowable Charge for the surgeon; VV) For non-durable medical equipment; except diabetic testing monitors and supplies; WW) For charges for funeral arrangements;

XX) For charges for financial or legal counseling; including estate planning or drafting of will; YY) For charges for homemaker or caretaker services; ZZ) For charges for respite care. This is care furnished during a period of time when the person's family or

usual caretaker cannot, or will not, attend to the person's needs. AAA) For any charges that are for therapy, supplies, drugs or counseling for sexual dysfunctions or

inadequacies; BBB) For any health/dental services or supplies obtained from a Foreign Health Care Provider unless traveling

outside the United States. (This exclusion will be waived in a life-threatening emergency, injury, or accident.);


CCC) Expenses incurred as a result of an intentionally self-inflicted illness or injury; or from a suicide or attempted suicide, unless the result of an underlying medical condition (even if the medical condition was not previously diagnosed).

DDD) For charges in connection with a Covered Person's participation in a riot or insurrection; EEE) For marriage counseling; FFF) For charges for the treatment of a learning disability; GGG) For any Pre-existing Condition in excess of the amount payable, if any, as specified in the Section titled

Schedule of Benefits; HHH) Any Hospital expenses and Physician's charges relating to non-emergency Friday or Saturday Hospital

admission if surgery or treatment is not performed on the day or the day after an individual is admitted to the Hospital. Treatment is defined as specialized treatment that necessitates Hospital Confinements;

III) For charges for amniocentesis except when performed on women age 30 or older or when a history of

genetic disorders has been present in the family; JJJ) For midwife charges; KKK) For services and/or supplies related to acupuncture; LLL) Charges for orthopedic shoes or other supportive devices for the feet and orthotics unless prescribed by a

Network Provider; MMM) For charges for bereavement counseling; NNN) For charges for pastoral counseling; OOO) For any services and/or supplies rendered primarily for:

1) Environmental Sensitivity testing or treatment, or 2) Clinical Ecology testing or treatment, or 3) Inpatient allergy testing or treatment;

PPP) For any charges for structural or nonstructural changes to a house or vehicle; QQQ) For services and/or supplies related to the treatment of alopecia; RRR) For services and/or supplies provided by a Health Care Provider not currently recognized by the Texas

State Board of Insurance as eligible for reimbursement; SSS) The term Home Health Care Expenses shall not include:

1) Custodial Care; 2) Transportation services; 3) Any period during which the Covered Person is not under the continuing care of a legally qualified

Physician; 4) Expenses for Home Health Care services which are incurred by a Covered Person during any

Calendar Year which exceed the Maximum Number of visits shown in the Schedule of Benefits herein;

TTT) For charges with respect to any organ or tissue transplant for:

1) Living and/or travel expenses of the live donor or recipient;


2) Donor search and acceptability testing of potential living donors; 3) Expenses related to maintenance of life for purposes of organ or tissue donation;

4) Purchase of the organ or tissue; and

5) Any organ or tissue transplant procedure or any preparation procedures considered

experimental/investigational in nature. UUU) For situations when a claim is pended for information to assist in the adjudication process, such as

coordination of benefits, accident details and subrogation, student status, additional medical information, etc., failure to respond to such requests within 60 days will cause any claim(s) submitted to be denied.


Please note, Sections 1, 3, 4, 10, 11 and 15 do not apply to the Special

Package Plan.

Section 6. SPECIAL PACKAGE PLAN This option is available to eligible employees only. Dependents may not elect and may not participate in this option. This plan is intended to be offered only to employees who have other comprehensive major medical coverage BENEFITS UNDER SPECIAL PACKAGE PLAN Benefits for participants in this option consist solely of: Hospital Coverage Under this component of the Special Package Plan, the Plan will pay for $75 per day for eligible Hospital expenses (e.g., room and board, nursing services and other ancillary services received during the Hospital Confinement) for a maximum of 120 days per calendar year.

Enhanced Life Benefits Enhanced life benefit with an additional $25,000 in term life and AD&D coverage. This Coverage is in addition to the life and AD&D benefits for which you have enrolled under the Plan. Basic Dental Benefits

The Eligible Employee must enroll for one of the health plan options (Plan A,

Plan B or Plan C to have medical benefits under the Plan.


Section 7. Basic Dental Benefits These benefits are described below and on the following pages of this section.

BASIC DENTAL BENEFITS SCHEDULE OF BENEFITS Preventive Dental Basic Dental Major Dental Orthodontic Dental Deductible $0 $50 per Covered Person per calendar Year Coinsurance Coinsurance is based on Reasonable & Customary Charges

Plan pays 80%, Deductible waived

Plan pays 80% after Deductible

Plan pays 50% after Deductible*

*Subject to completion of a 1 year service waiting period.

Plan pays 50% after Deductible

Maximum Benefit $1,500 per Covered Person per calendar year $1,000 per Covered Person’s lifetime

The Plan will pay for services provided by a Dentist who is legally licensed in the USA to provide these services and supplies. DENTAL EXPENSES COVERED/LIMITED/EXCLUDED DESCRIPTION A. DENTIST. A Doctor of Dental Surgery (D.D.S.) or a Doctor of Medical Dentistry (D.M.D.) who holds a

lawful license authorizing the person to practice dentistry in the locale in which the service is rendered. A Dentist’s practice must be located within the United States. Non-USA providers shall not be Eligible.

B. ALTERNATIVE TREATMENT. There is often more than one method of satisfactory treatment for a given

dental condition. If this is the case, the Covered Dental Expenses will be limited to Reasonable and Customary charges which would be appropriate for these services and supplies which are customarily employed nationwide in the treatment of the disease or injury concerned and which are recognized by the dental profession to be appropriate methods of treatment in accordance with broadly accepted national standards of dental practice, taking into account the total current oral condition of the Covered Person.

C. EMERGENCY PALLIATIVE TREATMENT. Any dental procedures necessary to alleviate (but not cure)

acute pain or temporarily alleviate (but not cure) conditions requiring the immediate attention of a Dentist to prevent irreparable harm to the Covered Person.

D. BENEFITS PAYABLE. If, because of a non-occupational condition, a Covered Person, while covered for

benefits under this Section, incurs Covered Expenses, this Plan will pay the Benefit Percentage of Reasonable and Customary expenses in excess of the Deductible, if applicable. The Benefit Percentage, the Deductible, and the Maximum Benefits are shown above.

E. INCURRED DATE. The date the service is received. F. DEDUCTIBLE. The Deductible amount is the dollar amount of Covered Expenses, which must be paid

by the Covered Person before reimbursement for any additional Covered Expenses can be paid. The deductible applies separately to each Covered Person in each calendar year, subject to the following: When covered family members satisfy their Maximum Family Deductible limit, the family Deductible will be considered satisfied for all covered family members for the remainder of that calendar year.

G. BENEFITS PERCENTAGE. The percentage of benefits payable during any one (1) calendar year for

Reasonable and Customary charges after the Deductible amount is satisfied as shown above.


H. MAXIMUM BENEFITS. Benefits paid to any Covered Person for dental expenses for Preventive, Basic and Major Services (combined) in any one (1) calendar year, shall not exceed the maximum as specified in this Section. If orthodontic benefits are provided, the Orthodontic Services Maximum Benefit is also specified in this section.

I. COVERED EXPENSES. The term Covered Expense means an eligible charge actually incurred by, or on

behalf of, a covered person for the charges listed below but only if the expenses are incurred while such Covered Person is covered for Dental Expense Benefits and only to the extent that the services or supplies are recommended by a physician (or dentist) and are essential for the necessary care and treatment of the dental problem suffered by the Covered Person.

J. PRE-DETERMINATION OF BENEFITS. A charge incurred by a Covered Person is eligible only when

the dentist's proposed course of treatment ("Treatment Plan") has been submitted to and reviewed by the Plan Administrator, and returned to the dentist showing the estimated benefits. No Treatment Plan need be submitted if the total charges do not exceed $300 or if emergency care is required. A Treatment Plan is the dentist's report that:

1) Itemizes the dentist's recommended services, 2) Shows the dentist's charge for each service, 3) Is accompanied by supporting X-rays or other diagnostic records where required or requested by the

Plan Administrator. K. ELIGIBLE CHARGE. An Eligible Charge is one the dentist makes for a covered Preventive, Basic,

Major, or Orthodontic dental service furnished, provided the service: 1) Is on the list of dental services, * 2) Is part of a Treatment Plan as described above, and 3) Is not listed in the Exclusions under Dental Expense Benefits. *If a dental service is performed that is not on the list of dental services, but the list contains one (1) or

more other services that under customary dental practices are suitable for the condition being treated, for the purpose of coverage, the listed services that the Plan Administrator determines would produce a satisfactory result will be considered to have been performed.

The amount of the eligible charge for a service is equal to the charge made by the dentist, not to exceed

the maximum eligible charge applying to that service in the list of dental services. L. INCURRED CHARGE. A charge will be considered to be incurred: 1) For an appliance or modification of an appliance - on the date the appliance is seated.

2) For a crown, bridge or gold restoration - on the date the appliance is seated. 3) For root canal therapy - on the date the pulp chamber is opened.

4) For orthodontic treatment, the date the bands or appliances are inserted;

5) For all other services - on the date the service is received.

M. ORTHODONTIC CHARGES. Covered Expense for Orthodontic Procedures necessitated by: 1) An overbite or overjet of at least four (4) millimeters; or 2) Maxillary (upper) and mandibular (lower) arches in either protrusive or retrusive relation of at least

one cusp; or

3) Cross-bite; or


4) An arch length discrepancy of more than four (4) millimeters in either the upper or lower arch.

N. ORTHODONTIC PROCEDURES. Movement of teeth by means of active appliances to correct the position of mal-occluded or mal-positioned teeth

All other terms shall have the same meaning as specified in "DEFINITIONS". COVERED DENTAL EXPENSES PREVENTIVE SERVICES: (Covered at 80%. Deductible is waived.)

1) Two (2) dental examinations per calendar year;

2) Two (2) prophylaxis (cleaning of teeth) treatments per calendar year;

3) Two (2) bitewing X-rays per calendar year;

4) Topical application of fluoride solutions up to the age of nineteen (19) years;

BASIC SERVICES: (Covered at 80% after $50 annual deductible.)

1) Extractions; 2) Oral surgery - apicoectomies, impactions, and extractions (including alveolectomy, alveoplasty, and

tori removal in connection with extractions);

3) Local anesthesia or I.V. sedation for covered oral surgery; 4) General anesthesia when medically indicated and administered by a Physician other than the

operating dentist

5) Restorative services (filling); 6) Periodontal scaling, treatment, diagnosis, and surgery; 7) Diagnostic X-ray and full mouth series of X-rays, but not more than one (1) series per calendar year; 8) Repair or recementing of crowns, inlays, onlays, bridgework or dentures or relining of dentures; 9) Root canals; 10) Space maintainers for missing primary teeth; 11) Emergency palliative treatment; 12) Injection of antibiotic drugs by the attending dentist; 13) Consultation required by the attending dentist. MAJOR SERVICES: (Covered at 50% after $50 annual deductible/ 1yr waiting period.) 1) Initial fixed bridgework and dentures; 2) Replacement of bridgework or partial dentures when an additional tooth or teeth must be replaced; 3) Cast metal or ceramic material inlays, onlays, or crown restoration; 4) Replacement or modification of existing crowns, bridgework, or dentures that:


a) Are necessitated by the extraction of an additional natural tooth or teeth while covered under the Plan;

b) Cannot be made serviceable and were installed more than five (5) years before replacement or

modification; or

c) Are made necessary by the initial placement of an opposing denture while covered;

5) Initial fixed bridgework, dentures, or partial dentures replacing a tooth or teeth, all of which were extracted more than five (5) years before coverage. Twelve (12) months must have elapsed since the Effective Date of coverage under this Plan;

6) First installation (including adjustments during the six (6) month period following installation of a

removable denture (partial or full);

7) The existing denture is an immediate temporary denture and replacement by a permanent denture is required and done within twelve (12) months from the date the immediate temporary denture was installed;

8) Crowns and initial installation of fixed bridgework (including inlays and crowns to form abutments). LIMITATIONS UNDER DENTAL EXPENSE BENEFITS

In the case of an individual, other than a dependent younger than age five (5), whose Dental Expense Benefits starts more than thirty-one (31) days after that individual becomes eligible, the covered services received during the first year the benefits are in effect, will be limited to those made necessary by an accident occurring while covered, and to preventive or basic dental services included in the list of dental services under the headings "Visits and X-rays", "Visits and Examinations", "X-ray and Pathology" and "Restorative Dentistry".

EXCLUSIONS UNDER DENTAL EXPENSE BENEFITS

1) Anything not furnished by a dentist, except X-rays ordered by a dentist, and services by a licensed dental hygienist under the dentist's supervision; anything not necessary or not customarily provided for dental care;

2) Services, unless payment is legally required, for

a) furnished by or for the U.S. Government, or any other government, or

b) to the extent provided under any governmental program or law under which the individual is, or could be, covered;

3) An appliance, or modification of one (1), where an impression was made before the patient was

covered; a crown, bridge or gold restoration for which the tooth was prepared before the patient was covered;

4) Root canal therapy if the pulp chamber was opened before the patient was covered; 5) A crown, gold restoration, or a denture or fixed bridge or addition of teeth to one (1), if the work

involves a replacement or modification of a crown, gold restoration, denture or bridge installed less than five (5) years before;

6) A denture or fixed bridge involving replacement of teeth missing before the individual was covered,

unless it also replaces a tooth that is extracted while covered, and such tooth was not an abutment for a denture or fixed bridge installed during the preceding five (5) years.

7) Services due to an accident or disease covered under worker's compensation or similar law. 8) Replacement of lost or stolen appliances; appliances or restorations or procedures for the purpose of

splinting, or to alter vertical dimension or restore occlusion.


9) Orthodontics (a program to straighten teeth); treatment for temporomandibular joint problems;

services for cosmetic purposes unless made necessary by an accident occurring while covered. Facings on molar crowns or pontics are always considered cosmetic.

10) Any portion of a charge for a service in excess of the reasonable and customary charge (the charge

usually made by the provider when there is no coverage, not to exceed the prevailing charge in the area for dental care of a comparable nature, by a person of similar training and experience).

11) Expenses applied toward satisfaction of a Deductible under the Dental Expense Benefits. 12) Services and Supplies provided by a Dentist located outside the United States.

If a particular charge is covered under the Dental Expense Benefits and also under another part of any other plans for which Ysleta ISD shall have paid any part of the cost, the Dental Expense Benefit payment will be limited to the excess, if any, of the amount normally paid for that Benefit over the amount payable by all such other plans.

EXTENSION OF BENEFITS

If the Dental Expense coverage for you or a dependent is terminated, the protection will be extended to cover charges incurred within the next thirty (30) days for Basic Services, provided benefits would have been paid had the coverage remained in effect, and treatment was begun prior to the date of termination.


Section 8. ENROLLING FOR COVERAGE AND INDIVIDUAL EFFECTIVE DATE

ELIGIBLE EMPLOYEE An eligible enrolled employee's coverage will become effective on the first day of the first month following the satisfaction of the Waiting Period. The employee must enroll within 31 days of becoming eligible. Coverage is automatic for the Special Package Plan. An enrollment card must be completed by an employee and marked "waived" if the employee elects not to enroll one of the Plan options under the Comprehensive Medical Plan. If an eligible employee waives coverage for himself or herself, no coverage is available for their eligible dependents under the Plan. If an employee waives coverage for themselves and later wishes to be covered under the Plan, the employee must wait for the annual Open Enrollment. Where an individual is covered as an eligible employee under this Plan, they may not be additionally covered under this Plan as the dependent of another eligible employee of this Plan. Employees who fail to enroll for Coverage when initially eligible, as described in this section, are considered Late Enrollees. SPECIAL ENROLLMENT PERIODS There are a number of circumstances that qualify as Special Enrollment Periods. A Special Enrollment Period is an additional enrollment opportunity for the employee to enroll for Coverage following his or her initial eligibility date due to: (1) loss of other coverage; (2) marriage; (3) death; (4) divorce; (5) birth of a child; (6) adoption of a child; and (7) placement for adoption of a child. The specific conditions and limitations that apply to the Special Enrollment Period are described below. A) Loss of Other Coverage: Eligible Employees who are covered under another health plan and

subsequently lose such coverage are eligible for Coverage following the loss of the other coverage provided they submit a completed application to the Employer within thirty-one (31) following termination of the other coverage. If an employee submits the application within this thirty-one (31) enrollment period, Coverage will be effective no later than the 1st of month following the loss of other coverage. The employee is eligible only if (s)he submitted a written declination of Coverage to the Employer when (s)he was initially eligible to enroll under the Plan. As used herein, loss of the other coverage must be due to: (a) exhaustion of COBRA benefits; (b) loss of eligibility under the prior coverage; or (c) termination of contributions by the employer under the prior plan of coverage.

This Special Enrollment Period also applies to Dependents of Eligible Employees who decline enrollment when initially eligible under the Plan due to existing medical benefits under another health plan and state in writing at such time that this is the reason for declining enrollment, provided the application is submitted within the time frame set forth above and loss coverage under the other plan was for one of the reasons set forth above.

B) Birth or Adoption: In the event of the birth of a child or adoption or placement for adoption of a child, the

child will be eligible to enroll for Coverage under this provision provided an enrollment application is submitted to the Employer within thirty-one (31) days following the child’s birth date, adoption or placement for adoption. In the event the application is submitted within this enrollment period, Coverage shall be made effective on the birth date of the child, or on the date of adoption or the date the child has been placed for adoption. In addition, the Eligible Employee and spouse, if not already covered, will also be eligible to enroll for Coverage.

C) Marriage: In the event a Covered Employee marries after his or her Coverage has become effective, the

employee may add his or her spouse to the Coverage by submitting to the Employer a completed application within thirty-one (31) days of the event. In this event, Coverage will be effective no later than the first of the month following receipt of the completed request for Coverage.

If an eligible employee does not elect coverage for his/her dependent within the thirty-one (31) days that the employee first acquires eligible dependents, the dependent will be considered a Late Enrollee and the employee will be required to wait for the annual Open Enrollment.


ADDITIONAL SPECIAL ENROLLMENT RIGHTS A) Special Enrollment for Previously Enrolled Covered Persons Dependents who had ceased to be eligible to enroll in the plan prior to the passage of the patient Protection and Affordable Care Act shall be provided with a 30 day special enrollment opportunity. This special enrollment opportunity will begin November 1, 2010. All dependents whose coverage under this Plan had previously ended, or who were denied coverage (or were not eligible for coverage) because the availability of dependent coverage of children ended before age 26, are eligible to enroll, or re-enroll in the Plan or coverage under this special enrollment period. Coverage for dependents who enroll through this special enrollment opportunity must take effect no later than January 1, 2011 Covered persons who were previously enrolled, but were terminated from Plan participation because of a prior lifetime limitation provision shall be provided with a 30 day special enrollment opportunity. This special enrollment opportunity will begin November 1, 2010. All covered persons whose coverage under this Plan has previously ended, or who were denied coverage (or were not eligible for coverage because the prior lifetime limitation had been reached, are eligible to enroll, or re-enroll in the plan or coverage under this special enrollment period. Coverage for covered persons who enroll through this special enrollment opportunity must take effect no later than January 1, 2011. B) Medicaid or CHIP Coverage Employees and Dependents who are eligible for the Plan but not enrolled are entitled to enroll under the following circumstances:

1) The Employee’s or Dependent’s Medicaid or State Child Health Insurance Plan (i.e. CHIP) coverage has terminated as a result of loss of eligibility and the Employee requests coverage under the Plan within 60 days after the termination; or

2) The Employee or Dependent become eligible for a contribution / premium assistance subsidy under Medicaid or a State Child Health Insurance Plan (i.e. CHIP), and the Employee requests coverage under the Plan within 60 days after eligibility is determined.

CONTRIBUTIONS The amount of contribution required for coverage for each covered person shall be determined by the Plan Sponsor.


Section 9. INDIVIDUAL TERMINATION OF COVERAGE A) The coverage of any Covered Person covered under the Plan shall terminate on the earliest of the

following dates:

1) The date of termination of the Plan; or 2) The date his/her membership ceases in an eligible class or with respect to a dependent the date such

dependent no longer is an Eligible Dependent; or 3) The date all coverage or certain benefits are terminated on his/her particular class by modification of

the Plan; or 4) The date he/she becomes a full-time member of the Armed Forces of any country; or 5) The date he/she fails to make a required contribution to the Plan, if any; or 6) After the 31st day following the birth of a child, with respect to such child, unless prior to the expiration

of such thirty-one (31) day period your Employer has been notified of the birth of such child and you have agreed to make any required contributions; or

7) If sick or injured, the date Ysleta Independent School District notifies the Covered Person of termination

of coverage; or 8) For an employee who is on a leave of absence as defined under the Family and Medical Leave Act

(“FMLA”), at the end of the FMLA leave of absence provided the employee does not return to work as an Actively Working employee at the end of the such leave of absence; or

9) For an employee who is on other Employer-approved leave of absence, at the end of the approved

leave of absence provided the employee does not return to work as an Actively Working employee at the end of the such leave of absence; or

10) For an Eligible Dependent child is a full-time student and who is on a medically necessary leave of

absence, at the end of the approved leave of absence provided the Eligible Dependent child does not return to school as a full-time student at the end of such leave of absence; or

11) When the plan terminates; or 12) Death of a Covered Person

B) The coverage of any person who continues coverage under this Plan as a Qualified Beneficiary, as defined

by the Continuation of Benefits Reconciliation Act (COBRA), shall end on the earliest of the following dates:

1) Thirty-six (36) months from the date a previously covered dependent continues coverage as a Qualified Beneficiary due to death of Employee, Medicare entitlement, divorce or separation, dependent ceasing to meet requirements of an Eligible Dependent as defined herein; or

2) The eighteen (18) months can be extended to twenty-nine (29) months when the beneficiary is determined by the Social Security Administration to be disabled at any time during the first sixty (60) days of COBRA coverage and notice of such determination is provided both within sixty (60) days of the determination and prior to termination of continuation coverage; or

3) Eighteen (18) months from the date a previously covered employee continues coverage as a COBRA Qualified Beneficiary due to a Qualifying Event taking place; or

4) For previously Covered Dependents, eighteen (18) months from the date an employee loses coverage due to voluntary or involuntary termination of employment; or

5) The date a Qualified Beneficiary becomes covered under another group health benefit plan which does

not include a Pre-existing condition clause, or is entitled to Medicare; or


6) The date a required contribution is not made.


Section 10. EXTENSION OF COVERAGE FOLLOWING TERMINATION CONTINUATION COVERAGE RIGHTS The COBRA Administrator is HealthSCOPE Benefits, Inc., 7430 Remcon Circle Bldg C, El Paso, TX 79912, 915-581-8182. The COBRA Administrator is responsible for performing certain administrative services related to COBRA continuation coverage. COBRA Continuation Coverage COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “COBRA qualifying event.” Specific COBRA qualifying events are listed later in this notice. COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” A qualified beneficiary is someone who will lose coverage under the Plan because of a COBRA qualifying event. Depending on the type of COBRA qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. A) If you are an employee, you will become a qualified beneficiary if you will lose your coverage under the

Plan because either one of the following COBRA qualifying events happens:

1) Your hours of employment are reduced; or 2) Your employment ends for any reason other than your gross misconduct.

B) If you are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following COBRA qualifying events happens:

1) Your spouse dies;

2) Your spouse’s hours of employment are reduced;

3) Your spouse’s employment ends for any reason other than his or her gross misconduct;

4) Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or

5) You become divorced or legally separated from your spouse.

C) Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan

because any of the following COBRA qualifying events happens:

1) The parent-employee dies;

2) The parent-employee’s hours of employment are reduced;

3) The parent-employee’s employment ends for any reason other than his or her gross misconduct;

4) The parent-employee becomes enrolled in Medicare (Part A, Part B, or both);

5) The parents become divorced or legally separated; or

6) The child stops being eligible for coverage under the plan as a “dependent child.” Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a COBRA qualifying event. If a proceeding in bankruptcy is filed with respect to Ysleta ISD and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee is a qualified beneficiary with respect to the bankruptcy. The retired employee’s spouse, surviving spouse, and dependent children will also be qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a COBRA qualifying event has occurred. When the COBRA qualifying event is the end of


employment or reduction of hours of employment, death of the employee, commencement of a proceeding in bankruptcy with respect to the employer, or enrollment of the employee in Medicare (Part A, Part B, or both), the employer must notify the Plan Administrator of the COBRA qualifying event within 30 days of any of these events. For the other COBRA qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator. The Plan requires you to notify the Plan Administrator within sixty (60) days after the COBRA qualifying event occurs. You must send this notice to: HealthSCOPE Benefits Administrators, Inc., COBRA Department, 7430 Remcon Circle Bldg C, El Paso, TX 79912. The notice needs to include the name, address, and telephone number, plan name and the COBRA qualifying event. If the COBRA qualifying event is a divorce or legal separation, legal documentation must be furnished. Failure to notify the Plan Administrator in the above stated time frames and prescribed manner will nullify your right to COBRA continuation of coverage. Once the Plan Administrator receives notice that a COBRA qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. For each qualified beneficiary who elects COBRA continuation coverage, COBRA continuation coverage will begin this Plan on the date of the COBRA qualifying event. COBRA continuation coverage is a temporary continuation of coverage. When the COBRA qualifying event is the death of the employee, enrollment of the employee in Medicare (Part A, Part B, or both), your divorce or legal separation, or a dependent child losing eligibility as a dependent child, COBRA continuation coverage lasts for up to thirty-six (36) months. When the COBRA qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage lasts for up to eighteen (18) months. There are two (2) ways in which this eighteen (18) month period of COBRA continuation coverage can be extended. Disability extension of eighteen (18) month period of continuation coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled at any time during COBRA continuation coverage and you notify the Plan Administrator in a timely fashion, within sixty (60) days, in writing you and your entire family can receive up to an additional eleven (11) months of COBRA continuation coverage, for a total maximum of twenty-nine (29) months. You must make sure that the Plan Administrator is notified of the Social Security Administration’s determination within sixty (60) days of the date of the determination and before the end of the 18-month period of COBRA continuation coverage. This notice should be sent to: HealthSCOPE Benefits Administrators, Inc., COBRA Department, 7430 Remcon Circle Bldg C, El Paso TX 79912. The notification should include the name, address, telephone number, plan name, and a copy of the Social Security Administration’s determination. Second COBRA qualifying event extension of eighteen (18) month period of continuation coverage If your family experiences another COBRA qualifying event while receiving COBRA continuation coverage, the spouse and dependent children in your family may obtain additional months of COBRA continuation coverage, up to a maximum of thirty-six (36) months. This extension is available to the spouse and dependent children if the former employee dies, gets divorced or is legally separated. The extension is also available to a dependent child when that child stops being eligible under the Plan as a dependent child. In all of these cases, you must make sure that the Plan Administrator is notified of the second COBRA qualifying event within sixty (60) days of the second COBRA qualifying event permitted under the terms. This notice must be sent to: HealthSCOPE Benefits Administrators, Inc., COBRA Department, 7430 Remcon Circle Bldg C, El Paso, TX 79912. The notification should include the name, address, telephone number, plan name, and COBRA qualifying event. Copies of documentation such as death certificate, Medicare card, divorce decree or legal separation papers must be included with the notification. If you have questions about your COBRA continuation coverage, you should HealthSCOPE Benefits Administrators, Inc., COBRA Department, 7430 Remcon Circle Bldg C, El Paso, TX 79912, telephone number 915-581-8182 or you may contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s web site at www.dol.gov/ebsa.

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Keep Your Plan Informed of Address Changes at all times In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Please note that, as it is the sole responsibility of the Plan participants to notify the Plan Administrator in writing of any address changes for all family members, you and/or your family members may lose their rights for continuation of coverage in the event documentation is not received or sent due to your failure to notify of an address change. How can you elect continuation coverage? Each qualified beneficiary listed on page one (1) of this notice has an independent right to elect continuation coverage. For example, both the employee and the employee’s spouse may elect continuation coverage, or only one (1) of them. Parents may elect to continue coverage on behalf of their dependent children only. A qualified beneficiary must elect coverage by the date specified on the Election Form. Failure to do so will result in loss of the right to elect continuation coverage under the Plan. A qualified beneficiary may change a prior rejection of continuation coverage any time until that date. In considering whether to elect continuation coverage, you should take into account that a failure to continue your group health coverage will affect your future rights under federal law. First, you can lose the right to avoid having Pre-existing condition exclusions applied to you by other group health plans if you have more than a sixty-three (63) day gap in health coverage, and election of continuation coverage may help you not have such a gap. Second, you will lose the guaranteed right to purchase individual health insurance policies that do not impose such Pre-existing condition exclusions if you do not obtain continuation coverage for the maximum time available to you. Finally, you should take into account that you have special enrollment rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within thirty (30) days after your group health coverage ends because of the COBRA qualifying event listed above. You will also have the same special enrollment right at the end of continuation coverage if you get continuation coverage for the maximum time available to you. How much does COBRA continuation coverage cost? Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The amount a qualified beneficiary may be required to pay may not exceed 102% (or, in the case of an extension of continuation coverage due to a disability, 150%) of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving continuation coverage.

Premium Reductions Under ARRA

The American Recovery and Reinvestment Act of 2009 (ARRA), as amended, provides for premium reductions for health benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985, commonly called COBRA. The premium assistance is also available for continuation coverage under certain State laws. “Assistance Eligible Individuals” pay only 35% of their COBRA premiums; the remaining 65% is reimbursed to the coverage provider through a tax credit. The premium reduction applies to periods of health coverage that began on or after February 17, 2009 and lasts for up to fifteen (15) months.

Eligibility for the Premium Reduction

An "assistance eligible individual" is the employee or a member of his/her family who elects COBRA coverage timely following a qualifying event related to an involuntary termination of employment that occurs at any point from:

A) September 1, 2008 through May 31, 2010; or

B) March 2, 2010 through May 31, 2010 if:

1) the involuntary termination follows a qualifying event that was a reduction of hours; and


2) the reduction of hours occurred at any time from September 1, 2008 through May 31, 2010 (a reduction of hours is a qualifying event when the employee and his/her family lose coverage because the employee, though still employed, is no longer working enough hours to satisfy the group health plan’s eligibility requirements).

C) Generally, the maximum period of continuation coverage is measured from the date of the original qualifying event, for Federal COBRA, this is generally eighteen (18) months. However, ARRA, as amended, provides that the fifteen (15) month premium reduction period begins on the first day of the first period of coverage for which an individual is “assistance eligible.” This is of particular importance to individuals who experience an involuntary termination following a reduction of hours. Only individuals who have additional periods of COBRA (or state continuation) coverage remaining after they become assistance eligible are entitled to the premium reduction.

D) For purposes of ARRA, COBRA continuation coverage includes continuation coverage required under Federal law (COBRA or Temporary Continuation Coverage) or a State law that provides comparable continuation coverage (for example, so-called "mini-COBRA" laws).

E) Those who are eligible for other group health coverage (such as a spouse's plan or new employer’s plan)

or Medicare are not eligible for the premium reduction. There is no premium reduction for periods of coverage that began prior to February 17, 2009.

F) Assistance eligible individuals who pay 35% of their COBRA premium must be treated as having paid the

full amount. The premium reduction (65% of the full premium) is reimbursable to the employer or health plan as a credit against certain employment taxes.

When and how must payment for continuation coverage be made? First payment for continuation coverage If you elect continuation coverage, you do not have to send any payment for continuation coverage with the Election Form. However, you must make your first payment for continuation coverage within forty-five (45) days after the date of your election. NOTE: This is the date the Election Notice is post-marked, if mailed. If you do not make your first payment for continuation coverage within such forty-five (45) day period, you will lose all continuation coverage rights under the Plan. Your first payment must cover the cost of continuation coverage from the time your coverage under the Plan would have otherwise terminated up to the time you make the first payment. You are responsible for making sure that the amount of your first payment is enough to cover this entire period. You may contact HealthSCOPE Benefits Administrators, Inc., 7430 Remcon Circle Bldg C, El Paso, TX 79912, telephone number 915-581-8182, to confirm the correct amount of your first payment. Your first payment for continuation coverage should be sent to: HealthSCOPE Benefits Administrators, Inc. COBRA Department. 7430 Remcon Circle Bldg C El Paso, TX 79912 Periodic payments for continuation coverage After you make your first payment for continuation coverage, you will be required to pay for continuation coverage for each subsequent month of coverage. Under the Plan, these periodic payments for continuation coverage are due on the 1st of each month of coverage. If you make a periodic payment on or before its due date, your coverage under the Plan will continue for that coverage period without any break. The Plan will send periodic notices of payments due for these coverage periods.


Periodic payments for continuation coverage should be sent to: HealthSCOPE Benefits Administrators, Inc. COBRA Department 7430 Remcon Circle Bldg C El Paso, TX 79912 Grace periods for periodic payments Although periodic payments are due on the dates shown above, you will be given a grace period of thirty (30) days to make each periodic payment. Your continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. However, if you pay a periodic payment later than its due date but during its grace period, your coverage under the Plan will be suspended as of the due date and then retroactively reinstated (going back to the due date) when the periodic payment is made. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a periodic payment before the end of the grace period for that payment, you will lose all rights to continuation coverage under the Plan. For more information This notice does not fully describe continuation coverage or other rights under the Plan. More information about continuation coverage and your rights under the Plan is available from the Plan Administrator. For more information about your rights, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA web site at www.dol.gov/ebsa. FAMILY MEDICAL LEAVE ACT Regardless of the established leave policies, the Plan shall at all times comply with FMLA. During any leave taken under FMLA, the Employee will maintain coverage under this Plan on the same conditions as coverage would have been provided if the covered Employee had been continuously employed during the entire leave period. The Family and Medical Leave Act is a Federal law that applies, generally, to employers with 50 or more Employees, and provides that an eligible Employee may elect to continue coverage under this Plan during a period of approved FMLA Leave at the same cost as if the leave had not been taken. If provisions under the Plan change while an Employee is on FMLA Leave, the changes will be effective for him or her on the same date as they would have been had he or she not taken leave. Eligible Employees Employees are eligible for FMLA Leave if all of the following conditions are met:

1. The Employee has been employed with the Participating Employer for at least 12 months; 2. The Employee has been employed with the Participating Employer at least 1,250 hours during the 12

consecutive months prior to the request for FMLA Leave; and 3. The Employee is employed at a worksite that employs at least 50 employees within a 75-mile radius.

Qualifying Circumstances for FMLA Leave Coverage under FMLA Leave is limited to a total of 12 workweeks during any 12-month period that follows:

1. The birth of, and to care for, a Son or Daughter; 2. The placement of a Child with the Employee for adoption or foster care; 3. The Employee’s taking leave to care for his or her Spouse, Son or Daughter, or Parent who has a Serious

Health Condition; 4. The Employee’s taking leave due to a Serious Health Condition which makes him or her unable to

perform the functions of his or her position; or

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5. A Qualifying Exigency arising out of the fact that a Spouse, Son, Daughter, or Parent of the Employee is a member of a regular or reserve component of the Armed Forces and is on (or has been notified of impending call to) covered active duty.

Coverage under FMLA Leave is limited to a total of 26 workweeks during any 12-month period for the following situations:

1. To care for a service member following a Serious Illness or Injury to that service member, when the Employee is that service member’s Spouse, Son or Daughter, Parent, or Next of Kin; or

2. To care for a veteran who is undergoing medical treatment, recuperation, or therapy for a Serious Illness or Injury that occurred any time during the five years preceding the date of treatment, when the Employee is that veteran’s Spouse, Son or Daughter, Parent, or Next of Kin.

This leave may be considered as a paid (accrued vacation time, personal leave or family or sick leave, as applicable) or unpaid leave. The Participating Employer has the right to require that all paid leave be used prior to providing any unpaid leave.

An Employee must continue to pay his or her portion of the Plan contribution, if any, during the FMLA Leave. Payment must be made within 30 days of the due date established by the Plan Administrator. If payment is not received, coverage will terminate on the last date for which the contribution was received in a timely manner.

Notice Requirements An Employee must provide at least 30 days’ notice to his or her Participating Employer prior to beginning any leave under FMLA. If the nature of the leave does not permit such notice, the Employee must provide notice of the leave as soon as possible. The Participating Employer has the right to require medical certification to support the Employee’s request for leave due to a Serious Health Condition for the Employee or his or her eligible family members.

Length of Leave During any one 12-month period, the maximum amount of FMLA Leave may not exceed 12 workweeks for most FMLA related situations. The maximum periods for an Employee who is the primary care giver of a service member with a Serious Illness or Injury that was Incurred in the line of active duty may take up to 26 weeks of FMLA Leave in a single 12-month period to care for that service member. The Participating Employer may use any of four methods for determining this 12-month period.

If the Employee and his or her Spouse are both employed by the Participating Employer, FMLA Leave may be limited to a combined period of 12 workweeks, for both Spouses, when FMLA Leave is due to:

1. The birth or placement for adoption or foster care of a Child; or 2. The need to care for a Parent who has a Serious Health Condition.

Termination of FMLA Leave Coverage may end before the maximum 12-week (or 26-week) period under the following circumstances:

1. When the Employee informs his or her Participating Employer of his or her intent not to return from leave; 2. When the employment relationship would have terminated but for the leave (such as during a reduction in

force); 3. When the Employee fails to return from the leave; 4. If any required Plan contribution is not paid within 30 days of its due date; 5. The Participating Employer and/or Plan Administrator is advised and/or determines that no FMLA

Qualifying Circumstance occurred.

If an Employee does not return to work when coverage under FMLA Leave ends, he or she will be eligible for COBRA continuation of coverage at that time, in accordance with the parameters set forth by this Plan and applicable law.

Recovery of Plan Contributions The Participating Employer has the right to recover the portion of the Plan contributions it paid to maintain coverage under the Plan during an unpaid FMLA Leave if an Employee does not return to work at the end of the leave. This right will not apply if failure to return is due to the continuation, recurrence or onset of a Serious


Health Condition that entitles the Employee to FMLA Leave (in which case the Participating Employer may require medical certification) or other circumstances beyond the Employee’s control.

Reinstatement of Coverage The law requires that coverage be reinstated upon the Employee’s return to work following an FMLA Leave whether or not the Employee maintained coverage under the Plan during the FMLA Leave.

On reinstatement, all provisions and limits of the Plan will apply as they would have applied if FMLA Leave had not been taken. The Service Waiting Period and the Pre-existing Condition limitation will be credited as if the Employee had been continually covered under the Plan.

Definitions For this provision only, the following terms are defined as stated.

“Next of Kin” “Next of Kin” shall mean the nearest blood relative to the service member.

“Parent” “Parent” shall mean the Employee’s biological parent or someone who has acted as his or her parent in place of his or her biological parent when he or she was a Son or Daughter.

“Qualifying Exigency” “Qualifying Exigency” shall mean:

1. Short-notice deployment.

a. To address any issue that arises from the fact that a covered military member is notified seven or less calendar days prior to the date of deployment of an impending call or order to active duty in support of a contingency operation; and

b. Leave taken for this purpose can be used for a period of seven calendar days beginning on the date a covered military member is notified of an impending call or order to active duty in support of a contingency operation;

2. Military events and related activities.

a. To attend any official ceremony, program, or event sponsored by the military that is related to the active duty or call to active duty status of a covered military member; and

b. To attend family support or assistance programs and informational briefings sponsored or promoted by the military, military service organizations, or the American Red Cross that are related to the active duty or call to active duty status of a covered military member;

3. Childcare and school activities.

a. To arrange for alternative childcare when the active duty or call to active duty status of a covered military member necessitates a change in the existing childcare arrangement for a biological, adopted, or foster Child, a stepchild, or a legal ward of a covered military member, or a Child for whom a covered military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA Leave is to commence;

b. To provide childcare on an urgent, immediate need basis (but not on a routine, regular, or everyday basis) when the need to provide such care arises from the active duty or call to active duty status of a covered military member for a biological, adopted, or foster Child, a stepchild, or a legal ward of a covered military member, or a Child for whom a covered military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA Leave is to commence;

c. To enroll in or transfer to a new school or daycare facility, a biological, adopted, or foster Child, a stepchild, or a legal ward of the covered military member, or a Child for whom the covered military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA Leave is to commence, when enrollment or transfer is necessitated by the active duty or call to active duty status of a covered military member; and


d. To attend meetings with staff at a school or a daycare facility, such as meetings with school officials regarding disciplinary measures, parent-teacher conferences, or meetings with school counselors, for a biological, adopted, or foster Child, a stepchild, or a legal ward of the covered military member, or a Child for whom the covered military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA Leave is to commence, when such meetings are necessary due to circumstances arising from the active duty or call to active duty status of a covered military member;

4. Financial and legal arrangements.

a. To make or update financial or legal arrangements to address the covered military member’s absence while on active duty or call to active duty status, such as preparing and executing financial and healthcare powers of attorney, transferring bank account signature authority, enrolling in the Defense Enrollment Eligibility Reporting System (DEERS), obtaining military identification cards, or preparing or updating a will or living trust; and

b. To act as the covered military member’s representative before a Federal, State, or local agency for purposes of obtaining, arranging, or appealing military service benefits while the covered military member is on active duty or call to active duty status, and for a period of 90 days following the termination of the covered military member’s active duty status;

5. Counseling. To attend counseling provided by someone other than a health care Provider for oneself, for the covered military member, or for the biological, adopted, or foster Child, a stepchild, or a legal ward of the covered military member, or a Child for whom the covered military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA Leave is to commence, provided that the need for counseling arises from the active duty or call to active duty status of a covered military member;

6. Rest and recuperation. To spend time with a covered military member who is on short-term, temporary, rest and

recuperation leave during the period of deployment. Eligible Employees may take up to five days of leave for each instance of rest and recuperation;

7. Post-deployment activities.

a. To attend arrival ceremonies, reintegration briefings and events, and any other official ceremony or

program sponsored by the military for a period of 90 days following the termination of the covered military member’s active duty status; and

b. To address issues that arise from the death of a covered military member while on active duty status, such as meeting and recovering the body of the covered military member and making funeral arrangements; and

8. Additional activities. To address other events which arise out of the covered military member’s active duty or call to active duty status provided that the Participating Employer and Employee agree that such leave shall qualify as an exigency, and agree to both the timing and duration of such leave.

“Serious Health Condition” “Serious Health Condition” shall mean an Illness, Injury, impairment, or physical or mental condition that involves:

1. Inpatient care in a Hospital, hospice, or residential medical facility; or 2. Continuing treatment by a health care Provider (a doctor of medicine or osteopathy who is authorized to

practice medicine or Surgery, as appropriate, by the State in which the doctor practices, or any other person determined by the Secretary of Labor to be capable of providing health care services).

“Serious Illness or Injury” “Serious Illness or Injury” shall mean an Illness or Injury Incurred in the line of duty that may render the service member medically unfit to perform his or her military duties.

“Son or Daughter” “Son or Daughter” shall mean the Employee’s biological child, adopted child, stepchild, foster child, a child placed in the Employee’s legal custody, or a child for which the Employee is acting as the parent in place of the child’s natural blood related parent.


“Spouse” “Spouse” shall mean an Employee’s husband or wife. NOTE: For complete information regarding FMLA rights, contact the Participating Employer.

Continuation During USERRA Participants who are absent from employment because they are in the Uniformed Services may elect to continue their coverage under this Plan for up to 24 months. If a Participant elected to continue coverage under USERRA before December 10, 2004, the maximum period for continuing coverage is 18 months. To continue coverage, Participants must comply with the terms of the Plan, [including election during the Plan’s annual enrollment period,] and pay their contributions, if any. In addition, USERRA also requires that, regardless of whether a Participant elected to continue his or her coverage under the Plan, his or her coverage and his or her dependents’ coverage be reinstated immediately upon his or her return to employment, so long as he or she meets certain requirements contained in USERRA. Participants should contact their participating employer for information concerning their eligibility for USERRA and any requirements of the Plan.


Section 11. COORDINATION OF BENEFITS AND SUBROGATION A) COORDINATION OF BENEFITS

The Plan has been designed to help meet the cost of illness or injury. Since it is not intended that greater benefits be paid you than your actual medical expenses, the amount of benefits payable with the Plan will take into account any coverage a family member has with other "plans". The benefits under this Plan will be coordinated with the benefits of the other group health coverage plans or programs.

The Plan will always pay either: (i) the Plan’s regular Benefits in full, or (ii) a reduced amount which, when added to the benefits payable by Another Plan or Other Plans, will equal 100% of this Plan’s Allowable Expenses.

Other Plan or Another Plan shall mean any plan, other than this Plan, providing benefits or services for or by reason of medical treatment, which benefits or services are provided by any of the following:

1) Group, blanket or franchise insurance coverage;

2) Service plan contracts, group practice, individual practice or other prepayment coverage;

3) Any coverage under labor-management trusteed plans, union welfare plans, employer organization

plans, or employee benefit organization plans;

4) Any coverage under governmental programs and any coverage required or provided by any statute;

5) Group or individual no-fault automobile contracts or group traditional automobile medical expense contracts; and

6) Student coverage obtained through an educational institution above the high school level.

Allowable Expenses shall mean the Reasonable and Customary charge for any Medically Necessary, eligible item of expense, at least a portion of which is covered under a plan. When some Other Plan pays first, this Plan’s Allowable Expenses shall consist of the Plan Participant's responsibility, if any, after the Other Plan has paid but shall in no event exceed the Other Plan’s Allowable Expenses. When some Other Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered, in the amount that would be payable in accordance with the terms of the Plan, shall be deemed to be the benefit. Benefits payable under any Other Plan include the benefits that would have been payable had claim been duly made therefore.

B) SUBROGATION AND RIGHT OF RECOVERY What is Subrogation? Subrogation applies to situations where the Covered Person is injured and another party is responsible for payment of health care expenses (s)he incurs because of the injury. The other party may be an individual, insurance company or some other public or private entity. Automobile accident injuries or personal injury on another’s property are examples of cases frequently subject to subrogation. The Subrogation provision allows for the right of recovery for certain payments. Any payments made for the Covered Person’s injuries under the Plan may be recovered from the other party. Any payments made to the Covered Person for such injury may be recovered from the Covered Person from any judgment or settlement of his or her claims against the other party or parties. By accepting Coverage under the Plan, the Covered Person automatically assigns to the Plan any rights the Covered Person may have to recover all or part of any payments made by the Plan from any other party, including an insurer or another group health program. Therefore, the Plan Administrator may act as the Covered Person’s substitute in the event any payment made by this Plan for health care benefits, including any payment for a Pre-existing Condition, is or becomes the responsibility of another party. Such payments shall be referred to as Reimbursable Payments. This assignment allows the Plan to pursue any claim that the Covered Person may have, whether or not the Covered Person chooses to pursue that claim.


The Covered Person must cooperate fully and provide all information needed under the Plan to recover payments, execute any papers necessary for such recovery, and do whatever else is necessary to secure such rights to the Plan. The other party may be sued in order to recover the payments made for the Covered Person under the Plan. Right of Reimbursement and Recovery Specifically, by accepting Coverage under the Plan the Covered Person agrees that if the Covered Person receives any recovery in the form of a judgment, settlement, payment or compensation (regardless of fault, negligence or wrongdoing) from (1) a tortfeasor, (2) a liability insurer for a tortfeasor, or (3) any other source, including but not limited to any form of insured or underinsured motorist coverage, any medical payments, no-fault or school insurance coverages, workers’ compensation coverage, premises liability coverage, any medical malpractice recovery, or any other form of insurance coverage (“Recovery”), the Covered Person must repay the Plan in full for any medical, dental, vision, or disability benefits which have been paid or which will in the future be payable under the Plan for expenses already incurred or which are reasonably foreseeable at the time of such Recovery. Pursuant to Sereboff v. Mid Atlantic Med. Servs., 126 S.Ct. 1869 (2006), the Plan has an equitable lien against the Recovery rights of the Covered Person and has the right to be paid from any such Recovery any and all monies or properties: (1) paid; (2) payable to; or (3) for the benefit of, a Covered Person to the extent of benefits paid by the Plan (“Subrogated Amount”), whether or not the Covered Person has been “made whole” for the injuries received. This right applies on a first-dollar basis (i.e., has priority over other rights), applies whether the funds paid to (or for the benefit of) the Covered Person constitute a full or partial recovery, and applies to funds paid for non-health care charges or attorney fees, or other costs and expenses. This right for first priority in contravention of the “make whole” doctrine shall not be affected or limited in any way by the manner in which the Covered Person or any person or entity responsible for paying any Recovery attempts to designate or characterize the Recovery, regardless of whether the recovery itemizes or identifies an amount awarded for Plan benefits or medical expenses, or is specifically linked to certain kinds of damages or payments. Payment of the Subrogated Amount to the Plan shall be without reduction, set-off or abatement for attorney’s fees or costs incurred by the Covered Person in the collection of damages. The Plan shall also be entitled to seek any other equitable remedy against any party possessing or controlling such monies or properties. At the discretion of the Plan Administrator, the Plan may reduce any future Eligible Expenses otherwise available to the Covered Person under the Plan by an amount up to the total amount of Subrogated Amount that is subject to the equitable lien. All rights of recovery will be limited to the amount of payments made under this Plan. The equitable lien shall also attach to the first right of Recovery to any money or property that is obtained by anybody, including but not limited to the Covered Person, the Covered Person’s attorney, and/or a trust for the direct or indirect benefit of the Insured or for his/her “special needs,” as a result of an exercise of the Covered Person’s rights of Recovery. The Plan may, in its sole discretion, require the Covered Person, as a pre-condition to receiving benefit payments, to sign a subrogation agreement and to agree in writing to assist the Plan to secure the Plan’s right to payment of the Subrogation Amount from the third party. In the event that the Plan does not receive payment of the Subrogated Amount, the Plan may, in its sole discretion, bring legal action against the Covered Person or reduce or set-off the unpaid Subrogated Amount against any future benefit payments to the Covered Person. If the Plan takes legal action to enforce its subrogation rights, the Plan shall be entitled to recover its attorneys’ fees and costs from the Covered Person. The following provisions apply to the Plan’s right of subrogation, reimbursement, and creation of an equitable lien:

1) “Pursue and Pay.” The Plan Administrator has elected a “pursue and pay” in connection with the subrogation, reimbursement and equitable lien rights. At its sole discretion, the Plan Administrator may elect to “pursue and pay” in connection with the subrogation, reimbursement and equitable lien rights for all claims involving Eligible Expenses of $500 or more. Pursuant to the election of “pursue and pay”, the Plan Administrator has the right to apply the subrogation, reimbursement and equitable lien rights prior to making any benefit payments under the Plan, and such payment shall be reduced by any amounts that were paid by any other party as described in this section.

2) Scope of Subrogation, Reimbursement and Equitable Lien Rights. The subrogation,

reimbursement and equitable lien rights apply to any benefits paid by the Plan on behalf of the Covered Person as a result of the Injuries sustained, including, but not limited to:


a) Any no-fault insurance; b) Medical benefits coverage under any automobile liability plan. This includes the Covered Person’s

Plan or any third party’s policy under which the Covered Person is entitled to benefits Under-insured and uninsured motorist coverage;

(i) Any automobile medical payments and personal injury protection benefits;

(ii) Any third party’s liability insurance

(iii) Any premises/guest medical payments coverage; (iv) Any medical malpractice recovery; (v) Workers’ compensation benefits. The right of subrogation, reimbursement and equitable lien

attach to any right to payment for workers’ compensation, whether by judgment or settlement, where the Plan has paid expenses otherwise eligible as Covered Services prior to a determination that the Covered Services arose out of and in the course of employment. Payment by Workers’ Compensation insurers or the employer will be deemed to mean that such a determination has been made.

(vi) Any other governmental agency reimbursement (i.e., state medical malpractice compensation

funds).

3) Excess Payments. If the Plan erroneously makes total payments that exceed the maximum amount to which the Covered Person is entitled at any time under the Plan, the Plan shall have the right to recover the excess amount from any persons to, or for, or with respect to whom such excess payments were made.

4) Reduction of Future Benefits. The Plan provides that recovery of excess amounts may include a

reduction of future benefit payments available to the Covered Person under the Plan of any amount up to the aggregate amount of Reimbursable Payments that have not been reimbursed by the Plan.

5) “Make Whole” and “Common Fund” Rules Do Not Apply. The provisions of the Plan concerning

subrogation, reimbursement, equitable liens and other equitable remedies are also intended to supersede the applicability of the federal common law doctrines and/or state laws commonly referred to as the “make whole” rule and the “common fund” rule.

6) No Deductions for Costs or Attorneys’ Fees. The reimbursement required under the Plan shall not be reduced to reflect any costs or attorneys’ fees incurred in obtaining compensation unless separately agreed to, in writing, by the Plan Administrator at the exercise of its sole discretion.


Section 12. ORDER OF BENEFITS DETERMINATION B) COORDINATION OF BENEFITS. The following rules will be used to establish the order of benefit

determination:

1) Where an individual is covered as an employee under one Plan and a dependent under another Plan, the Plan under which the individual is covered as an employee will be Primary and the Plan where the individual is covered as a dependent will be Secondary.

2) Where a dependent child is covered as an Eligible Dependent of an employee under this Plan and is

additionally covered as a dependent of an employee under another Plan, the benefit Plan which covers the dependent child of the employee with the earliest birth date (month/day) will be Primary and the other Plan will be Secondary, except that when a claim is made for a dependent child of divorced or separated parents, the following rules will apply:

a) A plan which covers a child as a dependent of a parent who by court decree must provide health

coverage will determine its benefits first;

b) When there is no court decree which requires a parent to provide health coverage to a dependent child, the following rules will apply:

(i) When a parent who has custody of the child has not remarried, that parent's plan will

determine its benefits first;

(ii) When a parent who has custody of the child has remarried:

(a) That parent's plan will determine its benefits first;

(b) The stepparent's plan will determine its benefits next; and

(c) The plan of the parent without custody will determine its benefits third.

3) When the rules in 2. above do not establish an order of benefit determination, the benefits of a plan which has covered the person on whose expenses claim is based for the longer period of time will be determined before the benefits of a plan which has covered the person the shorter period of time; and

4) When a plan does not contain a provision coordinating its benefits, that plan is always primary and

always pays first.

Where an individual is covered as an active employee or the dependent of an active employee, and is additionally covered under Title XVIII of the Social Security Act of 1965 as amended, the Plan will pay Primary and Medicare will pay Secondary for eligible expenses.

If, however, an individual is covered as an active employee or the dependent of an active employee and is additionally covered under Title XVIII of the Social Security Act of 1965 as amended because of Renal Dialysis or Kidney Transplant, the Plan coverage will be Primary only during the first thirty (30) months in which the individual is entitled to Medicare Benefits and the Plan will be Secondary to Medicare after this thirty (30) month period. If the Renal Dialysis or Kidney Transplant started on or after March 1, 1996, the Plan coverage will be Primary only during the first thirty (30) months in which the individual is entitled to Medicare Benefits and the Plan will be Secondary to Medicare after this thirty (30) month period

C) RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION. For the purpose of determining the

applicability of and implementing the terms of this provision of this Plan or any provision of similar purpose of any other plan, Ysleta Independent School District may, without the consent of or notice to any person, release to or obtain from any Insurance Company or other organization or person any information, with respect to any person, which Ysleta Independent School District deems to be necessary for such purposes. Any person, claiming benefits under this Plan will furnish to Ysleta Independent School District such information as may be necessary to implement this provision.


D) FACILITY OF BENEFIT PAYMENT. Whenever payments which would have been made under this Plan in accordance with this provision have been made under any other plans, Ysleta Independent School District will have the right, exercisable alone and in its sole discretion, to pay over to any organization making such other payments any amounts it will determine to be warranted in order to satisfy the intent of this provision, and amounts so paid will be deemed to be benefits paid under this Plan and, to the extent of such payments, Ysleta Independent School District will be fully discharged from liability under this Plan.

E) RIGHT OF RECOVERY. Whenever payments have been made by Ysleta Independent School District with

respect to Allowable Expenses in a total amount, at any time, in excess of the maximum amount of payment necessary at the time to satisfy the intent of this provision, Ysleta Independent School District will have the right to recover such payments, to the extent of such excess, from among one (1) or more of the following, as Ysleta Independent School District will determine: any persons to or for or with respect to whom such payments were made, any insurance companies, and other organizations.

YISD Summary Plan Description Effective 1-1-11 62

Section 13. CLAIMS PROCEDURE When the Covered Person receives Covered Services, a claim must be filed on the Covered Person’s behalf to obtain benefits. If the Provider is a Network Provider, the Network Provider will file the claim on your behalf. If you receive services from a Non-Network Provider, the Provider may not submit the claim on behalf of the Covered Person. If the Covered Person submits the claim, (s)he should use a claim form. It is in the Covered Person’s best interest to ask the Provider if the claim will be filed on his or her behalf by the Provider. CLAIM FORMS When the Covered Person is submitting the claim on his or her own behalf, (s)he may obtain a claim form from the Employer. If forms are not available, send a written request for claim forms to HealthSCOPE Benefits. Written notice of services rendered may also be submitted to HealthSCOPE Benefits without the claim form. The same information that would be given on the claim form must be included in the written notice of claim. This includes: 1) Name of patient;

2) Patient's relationship to the Covered Employee;

3) Identification number;

4) Date, type and place of service;

5) Name of Provider;

6) The explanation of benefits worksheet from the Primary carrier when filing for secondary claim benefits.

7) The Covered Person’s signature and the Provider's signature. TIME FRAME FOR SUBMITTING CLAIM All claims for benefits must be submitted by March 31st of the following calendar year. Claims not submitted to and received by the Plan Administrator by March 31st of the following calendar year are not eligible for payment by the Plan. Claims may be sent to: The claim form should be submitted to the address shown on the Covered Person’s identification card. CLAIMS REVIEW PROCEDURE This section describes the claims review procedures under the Plan. A claim is defined as any request for a benefit made by a Covered Person or by a Provider on behalf of the Covered Person that complies with the Plan’s reasonable procedure for making a claim for benefits. The times shown in this section are maximum times only. A period of time begins at the time the claim is filed. The days shown in this section are counted as calendar days. Under the Plan, the Covered Person can check on the status of a claim at any time by contacting the Customer Service number appearing on the Covered Person’s identification card. There are different time frames for reviewing a claim and providing notification concerning the claim. The time frames are based on the category of the claim. For the purpose of this provision, there are three categories of claims: Pre-Service Claims, Urgent Care Claims and Post-Service Claims. Pre-Service Claims – Pre-Service Claims are those claims for which the Plan requires prior notification and approval of the benefit prior to receiving the service. These are services, for example, that are subject to pre-certification, pre-authorization or pre-determination. For Pre-Service Claims (other than Urgent Care Claims), the following time frames apply concerning review and notification of the benefit determination: 1) Notification Concerning Failure to Follow Procedure – In the event the Covered Person, or Provider on

behalf of the Covered Person, fails to follow the proper procedure for providing notification of a Pre-Service


Claim, the Covered Person or Provider will be notified within five (5) days. 2) Benefit Determination Period – The Covered Person will be notified of the benefit determination within

fifteen (15) days following receipt of notification concerning the Pre-Service Claim. 3) Extension of Benefit Determination Period – If a benefit determination cannot be made within the standard

fifteen (15) day benefit determination period due to matters beyond the Plan Administrator’s control, the period may be extended by an additional fifteen (15) days, provided the Covered Person is notified of the need to extend the period prior to the end of the initial fifteen (15) day benefit determination period. Only one (1) extension is permitted for each Pre-Service Claim.

If a benefit determination cannot be made within the standard fifteen (15) day benefit determination period due to the Covered Person's failure to provide sufficient information to make the benefit determination, the benefit determination period may be extended, provided the Covered Person is notified of the need to extend the period. The Covered Person must be notified prior to the end of the initial fifteen (15) day benefit determination period. The notification must include a detailed explanation of the information needed in order to make the benefit determination. The Covered Person has forty-five (45) days following the receipt of the notification to provide the requested information.

Urgent Care Claims – Urgent Care Claims are those Pre-Service Claims in which the time periods for making claim determinations for Pre- or Post-Service Claims could seriously jeopardize the Covered Person’s life, health or ability to regain maximum function or when a Physician with knowledge of the Covered Person’s medical condition determines that the Covered Person would be subject to severe pain that cannot be adequately managed or controlled without the treatment that is the subject of the claim. For Urgent Care Claims, the following time frame applies concerning review and notification concerning the benefit determination: 1) Notification Concerning Incomplete Claim – In the event the Covered Person, or Provider on behalf of the

Covered Person, fails to submit complete information in connection with an Urgent Care Claim, the Covered Person or Provider will be notified of the specific information needed to complete the claim within twenty-four (24) hours.

2) Benefit Determination Period – The Covered Person will be notified of the benefit determination concerning

an Urgent Care Claim within seventy-two (72) hours following receipt of notification concerning the Urgent Care Claim.

3) Extension of Benefit Determination Period – In the event additional information is needed in order to make

a benefit determination, the Covered Person must be notified within twenty-four (24) hours following receipt of notification concerning the Urgent Care Claim. Notification of the extension will include a detailed explanation of the information needed to make the benefit determination. Upon receipt of the notification of the required extension, the Covered Person has forty-eight (48) hours to provide the requested information. The determination will be made within forty-eight (48) hours following receipt of the requested information from the Covered Person. If the Covered Person fails to provide the requested information, the benefit determination will be made within forty-eight (48) hours following the end of the period allowed for providing said information.

4) Benefit Determination Period For Request of Continuation of Treatment – Any request to continue the

course of treatment that is an Urgent Care Claim shall be decided as soon as possible. The Covered Person will be notified of the benefit determination within twenty-four (24) hours of the receipt of the claim, provided that such claim is made at least twenty-four (24) hours prior to the expiration of the prescribed period of time or number of treatments.

Post-Service Claims – Post-Service Claims are those claims for services, other than Pre-Service and Urgent Care Claims, which have been rendered by a Provider. For Post-Service Claims, the following time frames apply concerning review and notification of the benefit determination: 1) Benefit Determination Period – The Covered Person will be notified of the benefit determination within thirty

(30) days following receipt of notification concerning the Post-Service Claim. 2) Extension of Benefit Determination Period – If a benefit determination cannot be made within the standard


thirty (30) day benefit determination period due to matters beyond its control, the period may be extended by an additional fifteen (15) days, provided the Covered Person is notified of the need to extend the period prior to the end of the initial thirty (30) day benefit determination period. Only one (1) extension is permitted for each Post-Service Claim.

If a benefit determination cannot be made within the standard thirty (30) day benefit determination period due to the Covered Person's failure to provide sufficient information to make the benefit determination, the benefit determination period may be extended, provided the Covered Person is notified of the need to extend the period. The Covered Person must be notified prior to the end of the initial thirty (30) day benefit determination period. The notification must include a detailed explanation of the information needed in order to make the benefit determination. The Covered Person has forty-five (45) days following the receipt of the notification to provide the requested information.

CLAIMS APPEAL PROCESS

The Plan has a claims appeal process. The claims appeal process and the time limits associated with requesting and responding to a request for Claims Appeals are described in this section. The Covered Person and the Plan may have other voluntary alternative dispute resolution options, such as mediation. One (1) way to find out what may be available is to contact the local U.S. Department of Labor Office. Under the Plan, the Covered Person can check on the status of a claim appeal at any time by contacting the Customer Service number appearing on the reverse side of the Identification Card. Requesting a Claims Appeal – The Plan has a claims appeals process that allows the Covered Person to submit a request for appeal to the fiduciary that has been named by the Plan Administrator to review a claims appeal (“Named Fiduciary”). Under the Plan, the Plan Administrator will serve as the Named Fiduciary, unless the Plan Administrator has specifically delegated this responsibility to another party. The Named Fiduciary has the sole responsibility for making the decision on an appeal of an adverse benefit determination. Under the claims appeal process, the Covered Person will be provided with a full and fair review of an adverse benefit determination. This review of an adverse benefit determination must be done by an individual who is neither the individual who made the original adverse benefit determination nor the subordinate of such individual. In addition, if the adverse benefit determination is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug or other item is experimental, investigational, or not Medically Necessary, the Named Fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. In the event the Covered Person disagrees with a claims decision concerning the denial of a benefit or scope of benefits, the Covered Person or the Covered Person’s authorized representative may submit a request for appeal within 180 days from receipt of the notice of denial or adverse benefit determination. Absent an express written authorization by the Covered Person providing otherwise, the authorized representative includes a medical provider only for an Urgent Care Claims Appeal. Under the claims appeal process: 1) The Covered Person is permitted to submit written documents, comments, records and other information

relating to the claim;

2) The Covered Person is allowed reasonable access to any copies of documents, records and other information relevant to the claim;

3) The Covered Person is permitted to request the name of the medical provider used in making the initial adverse benefit determination; and

4) All comments, documents, records and other information submitted without regard to whether such

information was submitted or considered in the initial determination will be taken into account.


The Covered Person’s request for an appeal of an adverse benefit determination for a Pre-Service and Post-Service Claims must be submitted in writing and should be submitted to:

Named Fiduciary c/o HealthSCOPE Benefits, Inc. 7430 Remcon Circle Building C

El Paso, TX 79912 If the Covered Person’s request for appeal is not submitted to the Named Fiduciary in the manner described in this section, it will not be considered a “claims appeal” under the Plan. Under this Plan, HealthSCOPE Benefits, Inc. is not the Named Fiduciary for purposes of reviewing claims appeals under the Plan, but is instead acting strictly at the request of the Plan Administrator to coordinate receipt of appeals on behalf of the Plan. In the event that the answer given to the employee by the Plan Administrator to any of these questions is not satisfactory, the employee may request the officer in charge of Employee Benefits to initiate a review as described in Section 14(L), titled Review Procedure. Time Frame for Claims Appeal Review For Pre-Service Claim – All Pre-Service Claim Appeals will be reviewed and written notification of the Named Fiduciary’s decision will be prepared and mailed to the Covered Person who submitted the claim appeal within thirty (30) days of receiving the request for appeal of a Pre-Service Claim. As used in this section, a Pre-Service Claim Appeal is an appeal for any adverse claims determination in connection with a Pre-Service Claim. Time Frame for Claims Appeal Review for Urgent Care Claim – An Urgent Care Claim Appeal will be reviewed immediately and the Covered Person will be notified of the Named Fiduciary’s decision within seventy-two (72) hours of receiving the request for appeal. Because of the urgency related to Urgent Care Claim Appeals, all notifications concerning an appeal decision may be made verbally, or by fax or other electronic means. As used in this section, an Urgent Care Claim Appeal is an appeal for any adverse claims determination in connection with an Urgent Care Claim. Time Frame for Claims Appeal Review For Post-Service Claim – All Post-Service Claim Appeals will be reviewed and written notification of the Named Fiduciary’s decision will be prepared and mailed to the Covered Person who submitted the claim appeal within sixty (60) days of receiving the request for appeal of a Post-Service Claim. As used in this section, a Post-Service Claim Appeal is an appeal for any adverse claim determination in connection with a Post-Service Claim. Note: If the Plan Fiduciary is a multi-employer plan which has a committee or board of trustees designated as the appropriate Named Fiduciary which holds regular meetings (at least once a quarter), and if the appeal request is received within thirty (30) days preceding the date of the next scheduled meeting, then the Named Fiduciary will make the determination concerning the claims appeal no later than the date of second meeting following receipt of the request. If special circumstances (such as the need to hold a hearing, if the Plan’s procedures allow for such a hearing) require a further extension of time for processing an appeal request, a determination shall be rendered not later than the third meeting of the committee or board of trustees following the Plan’s receipt of the request for review. In this instance, the Plan Administrator shall provide to the Covered Person written notification of the extension and such notice shall describe the special circumstances and the date as of which the determination will be made, prior to the commencement of the extension. The Covered Person will be notified of the Named Fiduciary’s decision concerning the appeal no later than five (5) days after the determination is made by Named Fiduciary. Information Included in an Adverse Appeal Determination – All adverse appeal determinations will include the following information: 1) The reason for the determination;

2) The reference to the specific plan provision(s) on which the benefit determination is based;

3) A statement that the Covered Person is entitled to receive free of charge access to and copies of documents


and records pertinent to the claim; 4) A statement of the Covered Person’s right to bring a civil action under ERISA section 502(a), which right only

applies if the Plan is an ERISA plan.

5) A statement of the Covered Person’s right to obtain free of charge, internal rules, guidelines, protocols, or other similar criterion used in making the adverse determination; and

6) Either an explanation of the scientific or clinical judgment for the determination applying the terms of the Plan, or a statement that such explanation may be obtained free of charge upon request if the claim was denied on the basis of medical necessity or Experimental or Investigative grounds.

The decision of the Named Fiduciary with regard to an appeal is final.


Section 14. GENERAL PROVISIONS AND INFORMATION A) SUMMARIES. Ysleta Independent School District will make this SPD available through its web site or

will, upon request of any Covered Person issue or otherwise make available this SPD to such Covered Person. Such SPD summarizes the benefits to which the Covered Person is entitled, to whom benefits are payable, and the provisions of this Plan principally affecting said Covered Person and his/her dependents.

B) FUNDING. Medical claims are paid directly by Ysleta Independent School District Health Benefits Fund.

Ysleta Independent School District has employed a Plan Administrator to assure accurate, impartial and timely payment of benefits to and in behalf of Covered Employees and Dependents. The contributions payable to the trust shall not exceed the Plan's qualified cost for the taxable year as provided by Internal Revenue Code Sections 419 and 419A; which limitations are hereby incorporated into this Plan by reference.

C) CONFORMITY WITH STATUTES. Any provision of the Plan which on its Effective Date is in conflict with

the statutes of the United States or of the jurisdiction of Texas is hereby amended to conform to the minimum requirements of such statutes.

D) CLAIMS PROCEDURE. Ysleta Independent School District upon receipt of notice required by the Plan,

will furnish to any Covered Person or to any other person notifying Ysleta Independent School District of Claim such forms as usually furnished by it for filing proof of loss. Failure to furnish notice or proof of claim within the time provided in the Plan shall not invalidate or reduce any claims if it shall be shown not to have been reasonably possible to furnish such notice or proof and that such notice or proof was furnished as soon as possible.

E) QUESTIONS RELATING TO ELIGIBILITY. All questions relating to eligibility, classification, or coverage

under the Plan shall be submitted to the Plan Administrator. F) REVIEW PROCEDURE. Ysleta Independent School District maintains a Benefits Advisory Committee to

review appeals in accordance with their standard established policy. G) REFUND OF BENEFIT PAYMENTS. If the Plan Administrator pays benefits for covered expenses

incurred by a Covered Person and it is found that the payment was more than it should have been, or was made in error, the Plan has the right to a refund from the Covered Person to or for whom such benefits were paid, any insurance company or carrier, or any other organization. If no refund is received, the Plan may deduct any refund due it from any future benefit payment.

H) PHYSICAL EXAMINATION. The Plan Administrator, at the expense of the Plan, will have the right and

opportunity to examine the person or any individual whose Injury or Illness is the basis of a claim when and as often as it may reasonably require while the claim is pending.

I) LIMITATION.

1) No action at law or in equity can be brought to recover after the expiration of two (2) years after the time Written Proof of Loss is required to be furnished to the Plan Administrator.

2) No lawsuit or action in law or equity may be brought by you or on your behalf unless:

a) You have fully complied with all the provisions of the Plan, including all of the procedures and

requirements of the Claims Procedure and Review Procedure; and

b) The Plan Administrator has either denied in writing your request for review of the claim determination or has not provided a written response to your request for review within sixty (60) days after receiving the request; and

c) Such lawsuit or action is brought within two (2) years from the expiration of the time within which

Written Proof of Loss is required to be furnished under the Plan.


J) FACILITY OF PAYMENT. If, in the opinion of Ysleta Independent School District, a valid release cannot be rendered for the payment of any benefit payable under this Plan, Ysleta Independent School District may, at its option, make such payment to the individuals as have, in Ysleta Independent School District's opinion, assumed the care and principal support of the Covered Person and are therefore equitably entitled thereto. In the event of the death of the Covered Person prior to such time as all benefit payments due him/her have been made, Ysleta Independent School District may, at its sole discretion and option, honor benefit assignments, if any, prior to the death of such Covered Person. Any payment made by Ysleta Independent School District in accordance with the above provisions shall fully discharge Ysleta Independent School District to the extent of such payment.

K) FIDUCIARY OPERATION. Each fiduciary shall discharge his/her duties with respect to the Plan solely in

the interest of the participants and beneficiaries and

1) For the exclusive purposes of providing benefits to participants and their beneficiaries and defraying reasonable expenses of administering the Plan,

2) With care, skill, prudence and diligence under the circumstances then prevailing that a prudent

person acting in a like capacity and familiar with such matters would use in the conduct of an enterprise of alike character and with like aims.

L) PLAN ADMINISTRATION. The Administrator shall have full charge of the operation and management of

the Plan.

The Plan Sponsor and Plan Administrator may designate any person or persons to carry out their respective responsibilities. Any person or group of persons may serve in more than one fiduciary capacity with respect to the Plan.

M) NETWORK ADMINISTRATOR. The Network Administrator shall have the authority and responsibility to:

1) Carry out the responsibilities related to the program it administers in accordance with the provisions specified;

2) Determine which Network Providers will be eligible for Network participation, which Network Providers

are selected for Network participation and which Network Providers should be terminated from Network participation;

3) Perform all other responsibilities delegated to the Network Administrator in the instrument appointing

the Network Administrator. N) PLAN MODIFICATION AND AMENDMENTS OF PLAN. The Plan and any provision thereof may be

modified or amended at any time by Ysleta Independent School District upon its due approval of such modification or amendment. The modification or amendment will be effective at the date of approval or at such later date as Ysleta Independent School District may determine in connection therewith. Such modification or amendment shall be duly incorporated in writing into the master copy of the Plan on file with Ysleta Independent School District or written copy thereof shall be deposited with such master copy of the Plan.

O) PLAN TERMINATION. The Plan may be terminated at any time by Ysleta Independent School District

upon due authorization of such termination effective as of the date of such authorization or at such later date as Ysleta Independent School District may provide. In the event of such termination, Ysleta Independent School District shall have no obligation under the Plan beyond paying the difference between the claims incurred (even though later filed) and expenses of the Plan due up to the date of termination. Such claims and expenses shall be paid from the funds as normal expenses of the Plan.

P) PLAN IS NOT A CONTRACT OF EMPLOYMENT. The Plan shall not be deemed to constitute a contract

of employment between Ysleta Independent School District and nothing in this Plan shall be deemed to give any Employee the right to be retained in the service of Ysleta Independent School District or to interfere with the right of Ysleta Independent School District to discharge any Employee at any time.

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Section 15. INDIVIDUAL PRIVACY RIGHTS POLICY AND PROCEDURES Policy The Plan has implemented policies and procedures to ensure Covered Person privacy rights as required by and specified in the Privacy rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996. Procedure Covered Persons in the Plan have the right to. Receive a paper copy of the Plan's Notice of Privacy Practices ["Notice"], even if Covered Person has agreed previously to receive the Notice electronically; Request restrictions on the uses and disclosures of Protected Health Information ["PHI"]; Request to receive confidential communication by an alternative means or at an alternative location if appropriate cause is shown; Access documents in the designated record set for inspection and/or copying; Request to amend documents in the designated record set that are inaccurate or incomplete; and Obtain an accounting of disclosures of their PHI. The Plan adheres to policies and procedures developed and implemented to ensure a Covered Person’s privacy rights. The Plan provides workforce members who perform plan administration functions with annual training regarding individual rights with respect to their PHI. A) NOTICE OF PRIVACY PRACTICES POLICY AND PROCEDURES Policy The privacy practices of the Plan designed to protect the privacy, use and disclosure of Protected Health Information (PHI), are clearly delineated in the Plan's Notice of Privacy Practices [Notice] which was developed and is used in accordance with the Privacy Rule. The Plan and the Plan Sponsor will comply with the security regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, 45 C.F.R. Parts 160, 162 and 164 (the "Security Regulations"). The following provisions apply to Electronic Protected Health Information ("ePHI") that is created, received, maintained or transmitted by the Plan Sponsor on behalf of the Plan, except for ePHI (1) it receives pursuant to an appropriate authorization (as described in 45 C.F.R. section 164.504(f)(1)(ii) or (iii)), or (2) that qualifies as Summary Health Information and that it receives for the purpose of either (a) obtaining premium bids for providing health insurance coverage under the Plan, or (b) modifying, amending or terminating the Plan (as authorized under 45 C.F.R. section 164.508). If other terms of the Plan conflict with the following provisions, the following provisions shall control. The Security Regulations are incorporated herein by reference. Unless defined otherwise in the Plan, all capitalized terms herein have the definition given to them by the Security Regulations. The Plan Sponsor shall, in accordance with the Security Regulations:

1) Implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the ePHI that it creates, receives, maintains or transmits on behalf of the Plan.

2) Ensure that "adequate separation" is supported by reasonable and appropriate security measures.

"Adequate separation" means the Plan Sponsor will use ePHI only for Plan administration activities and not for employment-related actions or for any purpose unrelated to Plan administration. Any employee or fiduciary of the Plan or Plan Sponsor who uses or discloses ePHI in violation of the Plan's security or privacy policies and procedures or this Plan provision shall be subject to the Plan's disciplinary procedure.

3) Ensure that any agent or subcontractor to whom it provides ePHI agrees to implement reasonable

and appropriate security measures to protect the information.

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Report to the Plan any Security Incident of which it becomes aware. Procedures The privacy practices of the Plan are described in its Notice. The Notice is distributed to all new participants at enrollment. All current participants received the Notice as of the compliance date. All participants receive a revised Notice within sixty (60) days of any material revision to the Notice. The Notice is provided to the named participant or employee for the benefit of all dependents. The Notice is available to anyone who requests it. Participants have the right to receive a paper copy of the Notice, even if they previously agreed to receive the Notice electronically. All current participants are notified at least once every three (3) years of the availability of the Notice and provided with instructions on how to obtain it. The Notice is given to all Business Associates. The Notice is reviewed with all current workforce members who perform the Plan functions during their initial training and annually thereafter. The Notice is revised as needed to reflect any changes in the Plan's privacy practices. Revisions to the policies and procedures are not implemented prior to the effective date of the revised Notice. When revisions to the Notice are necessary, all current participants, workforce members who perform the Plan functions and Business Associates receive a revised copy of the Notice. The Privacy Official retains copies of the original Notice and any subsequent revisions for a period of six (6) years from the date of its creation or when it was last in effect, whichever is later. All workforce members who perform the Plan functions and Business Associates are required to adhere to the privacy practices as detailed in the Notice, Privacy Policies and Procedures and Business Associate Contracts. Violations of the Plan's privacy practices will result in disciplinary action up to and including termination of employment or contracts. The Notice is prominently displayed and available electronically on the Plan's Web site at http://www.yisd.net/ B) NOTICE OF THE PLAN'S PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. USE AND DISCLOSURE OF HEALTH INFORMATION The Plan may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), for purposes of making or obtaining payment for your care and conducting health care operations. The Plan has established a policy to guard against unnecessary disclosure of your health information. The following is a summary of the circumstances under which and purposes for which your health information may be used and disclosed: To Make or Obtain Payment. The Plan may use or disclose your health information to make payment to or collect payment from third parties, such as other health plans or providers, for the care you receive. For example, the Plan may provide information regarding your coverage or health care treatment to other health plans to coordinate payment of benefits.

http://www.yisd.net/�

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To Conduct Health Care Operations. The Plan may use or disclose health information for its own operations to facilitate the administration of the Plan and as necessary to provide coverage and services to all of the Plan's Covered Persons. Health care operations include such activities as:

Quality assessment and improvement activities.

Activities designed to improve health or reduce health care costs.

Clinical guideline and protocol development, case management and care coordination.

Contacting health care providers and Covered Persons with information about treatment alternatives and other related functions.

Health care professional competence or qualifications review and performance evaluation.

Accreditation, certification, licensing or credentialing activities. Underwriting, premium rating or

related functions to create, renew or replace health insurance or health benefits.

Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.

Business planning and development including cost management and planning related analyses

and formulary development.

Business management and general administrative activities of the Plan, including customer service and resolution of internal grievances.

Certain marketing activities.

For example, the Plan may use your health information to conduct case management, quality improvement and utilization review, and provider credentialing activities or to engage in customer service and grievance resolution activities.

For Treatment Alternatives. The Plan may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. For Distribution of Health-Related Benefits and Services. The Plan may use or disclose your health information to provide to you information on health-related benefits and services that may be of interest to you. For Disclosure to the Plan Sponsor. The Plan may disclose your health information to the Plan Sponsor for plan administration functions performed by the Plan Sponsor on behalf of the Plan. The Plan also may provide summary health information to the Plan Sponsor so that the Plan Sponsor may solicit premium bids from other health plans or modify, amend or terminate the Plan. When Legally Required. The Plan will disclose your health information when it is required to do so by any federal, state or local law. To Conduct Health Oversight Activities. The Plan may disclose your health information to a health oversight agency for authorized activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. The Plan, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of or is not directly related to your receipt of health care or public benefits. In Connection With Judicial and Administrative Proceedings. As permitted or required by state law, the Plan may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when the Plan makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

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For Law Enforcement Purposes. As permitted or required by state law, the Plan may disclose your health information to a law enforcement official for certain law enforcement purposes, including, but not limited to, if the Plan has a suspicion that your death was the result of criminal conduct or in an emergency to report a crime. In the Event of a Serious Threat to Health or Safety. The Plan may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Plan, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public. For Specified Government Functions. In certain circumstances, federal regulations require the Plan to use or disclose your health information to facilitate specified government functions related to the military and veterans, national security and intelligence activities, protective services for the President and others, and correctional institutions and inmates. For Worker's Compensation. The Plan may release your health information to the extent necessary to comply with laws related to worker's compensation or similar programs. LIMIT DISTRIBUTION, USE OR REQUESTS TO LIMITED DATA SET Under the American Recovery and Reinvestment Act of 2009 (ARRA), the Health Plan will be required to limit its distribution, use or requests for protected health information, to the extent practicable, to a limited data set, or if more information is needed, to the minimum necessary amount of information needed to accomplish the intended purpose of the data use. The Secretary of HHS shall issue guidance on what constitutes minimum necessary for the purposes of this provision no later than eighteen (18) months following the enactment of this provision under ARRA. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION Other than as stated above, the Plan will not disclose your health information other than with your written authorization. If you authorize the Plan to use or disclose your health information, you may revoke that authorization in writing at any time. YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION You have the following rights regarding your health information that the Plan maintains: Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on the Plan's disclosure of your health information to someone involved in the payment of your care. However, the Plan is not required to agree to your request. If you wish to make a request for restrictions, please contact the Ysleta ISD. Right to Receive Confidential Communications. You have the right to request that the Plan communicate with you in a certain way if you feel the disclosure of your health information could endanger you. For example, you may ask that the Plan only communicate with you at a certain telephone number or by email. If you wish to receive confidential communications, please make your request in writing to Ysleta ISD, the Plan will attempt to honor your reasonable requests for confidential communications. Right to Inspect and Copy Your Health Information. You have the right to inspect and copy your health information. A request to inspect and copy records containing your health information must be made in writing to Ysleta ISD. If you request a copy of your health information, the Plan may charge a reasonable fee for copying, assembling costs and postage, if applicable, associated with your request. Right to Amend Your Health Information. If you believe that your health information records are inaccurate or incomplete, you may request that the Plan amend the records. That request may be made as long as the information is maintained by the Plan. A request for an amendment of records must be made in writing to Ysleta ISD. The Plan may deny the request if it does not include a reason to support the amendment. The request also may be denied if your health information records were not created by the Plan, if the health information you are requesting to amend is not part of the Plan's records, if the health information you wish to amend falls within an exception to the health information you are permitted to inspect and copy, or if the Plan determines the records containing your health information are accurate and complete.

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Right to an Accounting. You have the right to request a list of disclosures of your health information made by the Plan for any reason other than for treatment, payment or health operations. The request must be made in writing to Ysleta ISD. The request should specify the time period for which you are requesting the information, but may not start earlier than April 14, 2003. Accounting requests may not be made for periods of time going back more than six (6) years. the Plan will provide the first accounting you request during any twelve (12) month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. The Plan will inform you in advance of the fee, if applicable. Make available to a Covered Person who request an accounting of disclosures of the Covered Person’s Protected Health Information the information required to provide an accounting of disclosures in accordance with 45 CFR §164.528. To the extent the Health Plan uses or maintains Electronic Health Records (EHRs), the Health Plan must be able to account for uses and disclosures of that information, even for treatment, payment and/or health care operations purposes. This detail must be retained for a period of at least three (3) years. You have a right to obtain a copy of the record in an electronic format and to direct the Health Plan to transmit a copy of the record to any entity or person designated by you. This provision is effective January 1, 2011 or the date EHR is acquired for all EHRs acquired after January 1, 2009. For EHRs acquired on or before January 1, 2009, the provision will be effective January 1, 2014. Right to a Paper Copy of this Notice. You have a right to request and receive a paper copy of this Notice at any time, even if you have received this Notice previously or agreed to receive the Notice electronically. To obtain a paper copy, please contact Ysleta ISD. (You also may obtain a copy of the current version of the Plan's Notice at its Web site, http://www.ysid.net/) DUTIES OF THE PLAN The Plan is required by law to maintain the privacy of your health information as set forth in this Notice and to provide to you this Notice of its duties and privacy practices. The Plan is required to abide by the terms of this Notice, which may be amended from time to time. The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If the Plan changes its policies and procedures, The Plan will revise the Notice and will provide a copy of the revised Notice to you within sixty (60) days of the change. You have the right to express complaints to the Plan and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. Any complaints to the Plan should be made in writing to Ysleta ISD. The Plan encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint. The Plan is required to notify each individual whose unsecured protected health information is the subject of a breach, or is reasonably believed to be subject of a breach. Notification must occur within sixty (60) days of the discovery of the breach. In addition, the Plan must notify the Secretary of the Department of Health and Human Services. If the breach involves 500 or more individuals, the Covered Entity is also required to notify a local media outlet serving the state or jurisdiction in which the individuals reside. This provision is effective 180 days after the enactment date of American Recovery and Reinvestment Act of 2009 (ARRA). The enactment date is February 17, 2009. CONTACT PERSON The Plan has designated the Benefits Coordinator as its contact person for all issues regarding patient privacy and your privacy rights. You may contact this person at (915) 434-0460. EFFECTIVE DATE This original effective date of this Notice is April 14, 2003, with revisions of February 17, 2009 and January 1, 2011. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT The Benefits Coordinator, Risk Management Department, 915-434-0460.

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Section 16. SPECIFIC PLAN INFORMATION A. Employer The employer’s legal name and address is:


9600 Sims Dr

El Paso, TX 79925

B. Plan Sponsor and Plan Administrator The Plan Sponsor and Plan Administrator is:


9600 Sims Dr

El Paso, TX 79925

C. Plan Name The name of the Plan is Ysleta Independent School District Health Care Trust Medical Plan. D. Plan Year The Plan Year is the twelve (12) month period which begins on January 1st and ends on December 31st of each year. E. Funding and Contributions The Ysleta Independent School District is self-insured for its medical plan (the “Plan”). The Ysleta Independent School District provides a major portion of the contributions necessary to properly fund these programs in order to make these benefits available F. Third Party Administrator The plan administrator has contracted with a third party administrator (TPA) to assist the plan administrator with claims adjudication. The TPA’s name, address and telephone number are:

HealthSCOPE Benefits Administrators, Inc.

7430 Remcon Cir Bldg C

El Paso, TX 79912

(915) 581-8182

(800) 854-2339 www.healthscopebenefits.com

The employer hereby adopts the provisions of this Plan, as restated, and its duly authorized officer has executed this plan document and summary plan description as effective this first day of ____________. By: __________________________________________ ________________________________ Dr. Michael Zolkoski, Superintendent Date

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