Regulatory Update Notice
On May 4, 2020, the Department of Labor published a temporary rule
that extends the deadlines to complete various actions as described
below.1
These deadlines are extended by disregarding the period from March
1, 2020 through sixty (60) days after the announced end of the
COVID-19 National Emergency (“Outbreak Period”). If no end to the
COVID-19 National Emergency is announced, the Outbreak Period ends
no later than April 29, 2021. This notice will be updated if an end
to the COVID-19 National Emergency is announced.
Specific changes under this notice include:
1. HIPAA Special Enrollment Period Extended – extends the 30-day
and 60-day HIPAA special enrollment timeframes by disregarding the
Outbreak Period;
2. COBRA Election Deadline Extended – extends the 60-day COBRA
election period by disregarding any days in the Outbreak
Period;
3. COBRA Premium Payment Period Extended – extends these 45- and
30-day COBRA premium payment timeframes, as applicable, by
disregarding the Outbreak Period;
4. COBRA Qualifying Event Notice Deadlines Are Extended – extends
these COBRA qualifying event timeframes by disregarding the
Outbreak Period;
5. Deadline for Filing ERISA Benefit Claims Extended – extends this
benefits claim deadline by disregarding the Outbreak Period;
6. Extension of Time for Filing ERISA Plan Appeals – the date
within which claimants may file an appeal of a benefit claim denial
has been extended by disregarding the Outbreak Period;
7. Timeframe Which Claimants May File a Request for an External
Review Extended – the date within which ERISA group health plan
claimants have to file a request for external review is extended by
disregarding the Outbreak Period;
8. Timeframe Which Claimants May File Information to Perfect a
Request for External Review Extended – extends the period that a
claimant has to file information to perfect their request for
external review by disregarding the Outbreak Period;
1 85 FR 26351-26355, May 4, 2020
City of Reno
Group Health Plan
1
The City of Reno Plan Document dated May 1, 2018 is hereby amended
effective January 1, 2020, as
follows:
The following is added to the Schedule of Medical Benefits on page
10:
Bariatric Surgery
Benefits are available only when services are provided through the
BARInet preferred provide network.
In-Network Out-of-Network
Not covered
professional consultations
copayments
40% after deductible
The following is added to page 25 in the Eligible Medical Expenses
section:
D. BARIATRIC SURGERY
a) Covered Employees and Dependents over age 18.
b) Employee must have one year of service with the City of
Reno.
c) Bariatric surgery services must be provided by a BARInet
Specialty Network Provider.
2. Program Requirements
minimums, comorbidities, participation in educational programs, and
others. Contact BARInet at 1-
866-868-1395 for detailed information about program requirements
and instructions for starting the
approval process.
Item #14 in the Medical Limitations and Exclusions section, page 27
is amended as follows:
Additional cosmetic surgery or medical procedures exclusions
include:
Complications resulting from excluded cosmetic surgery
Complications of medical procedures that result in conditions that
affect the
appearance of the body without commensurate impairment of bodily
function
Cosmetic treatment or service related complications, insertion,
removal or revision of
breast implants (including complications) unless provided post
mastectomy
Psychological and physical factors including but not limited to
self-image, difficult
social or peer relations, embarrassment in social situations,
inability to exercise or
participate in recreational activities comfortably, or impact on
ability to perform one’s job duties
Charges which result from appetite control, food addictions, eating
disorders (except
documented cases of bulimia or anorexia that meet standard
diagnostic criteria as
City of Reno
Group Health Plan
2
determined by Hometown Health and present significant symptomatic
medical
problems) or any treatment of obesity unless a Covered Employee
meets the Bariatric Surgery benefit guidelines outlined in Item D.
of the Eligible
Medical Expenses section.
Item #23 in the Medical Limitations and Exclusions section, page
27, is amended as follows:
Surgical or invasive treatment for obesity or morbid obesity
including but not limited to Gastric Restrictive services;
reversals and complications, unless the Covered Employee meets
the
Bariatric Surgery benefit guidelines outlined in Item D. of the
Eligible Medical Expenses section.
Add the following the Definitions section on page 61:
Bariatric Surgery -- under this Plan means Lab Gastric Bypass and
Lap Sleeve Gastrectomy only.
City of Reno
Group Health Plan
Plan Amendment (effective February 1, 2019)
The City of Reno Plan Document, dated May 1, 2018, is hereby
amended effective February 1, 2019, as follows:
1. Gender Reassignment listed in the ELIGIBLE MEDICAL EXPENSES on
page 17 is amended as follows:
13 G~nder ReHsignment - Gender· reassignment surgery consisting of
any combination of the following when
the following criterra is me ·
a. Requirements for mastectomy for femare:-to-rnar~ patients;
• Single Jette( of refetral from a. quafifre'¢1 rnenfal health
professional: and • Persistent, wellt-documented gerrde dyspnfflia,
and • Capacity fo make a fully nformed decision and to con.sen! for
treatment and • Age of mafority (18 years DJ age or old'er); 8Jld •
If slgni1lcanl medical or men!af lrlealth C!irlilcems are present.
they must be reasonably Ylt*I 00111tro fed.
b. Requirements for gonadectomy ,ti.ysreteciomy ar:Td oophorectomy
in female-to-mafe and orchiectomy in male-fo female):
• Two referral letters from quarified mental h:eallh professionals
. one in a purely evaluative rofe (see AppencfrlG);
• Persistent, well-documented) gender dysphorta; and • Capacity to
make a ·fully informed dedsioll and to consent for treatment; and •
Age of majoriiy (18 years of age or ofder}: and • If significant
medical or menial heallh concerns are present. they must be
reasonably well controlled; and • Twelve months of continuous
harm.one therapy as appropriate to the member's gender goals
{unless (he
member has a medical contraindication or is otherwise unable or
unwllling to take hormones).
c. Requirements for genital reconstructlve surgery (i.e.
vaginectomy, urethroplasty, metoidioplasty. phalloplasly,
scrotoplasty, and placement of a testicular prothesis and erectile
prosthesis in female to male, penectomy. vaginoplasty, labiaplasty,
and clitoroplasty ih male to female):
• Two referral letters from qualified mental health professionals,
one in a purely evaluative role (see Appendix);
• Persistent, well-documented gender dysphoria; and • Capacity to
make a fully informed decision and to consent for treatment; and •
Age of majority ( 18 years of age or older); and • If significant
medical or mental health concerns are present, they must be
reasonably well controlled: and • Twelve months of continuous
hormone therapy as appropriate to the member's gender goals (unless
the
member has a medical contraindication or is otherwise unable or
unwilling to take hormones); and • Twelve months of living in a
gender role that is congruent with their gender identity (real life
experience).
11Pa ge Plan Amendment #1 (effective February 1, 2019)
NOTE: Behavioral Health and Hormone Therapy in relation to gender
dysphoria is covered. Also, see Gender Reassignment under MEDICAL
LIMITATIONS AND EXCLUSIONS for i,ervices and procedures that are
not covered .
2. Gender Reassignment listed in the MEDICAL LIMITATION AND
EXCLUSIONS on page 30 is amended as follows:
70. Gender Reassignment - Surgery, services and supplies when the
criteria required under Gender Reassignment, listed in the Eligible
Medical Expenses section, is not meL Procedures that me be
performed as a component or a gender reassignment as cosmetic (not
an all-inclusive list) will not be covered: abdomlnoplasty,
blepharoplasty, brow lift, calf Implants, cheek/malar implants,
chin/nose implants, collagen injections, construction of a clitoral
hood, drugs for hair loss or growth, forehead lift, hair removal,
hair transplantation, lip reduction, liposuction, mastopexy, neck
tightening , pectoral implants, removal or redundant skin,
rhinoplasty, voice therapy/voice lessons.
NOTE: See Gender Reassignment under ELIGIBLE MEDICAL EXPENSES on
page 17 for services and procedures that are covered.
3. Mental health services listed in the ELIGIBLE MEDICAL EXPENSES
on page 20 is amended as follows:
24. Mental health services - Covered benefits for general mental
health (Including services related to the treatment of Attention
Deficit Disorder (ADD & ADHD)) and severe mental illness will
be provided under the same provisions as medical and surgical
benefits, with no additional financial or treatment
limitations.
NOTE: Behavioral health in relation to gender dysphoria is
covered.
4. Hormone Therapy is added to the ELIGIBLE MEDICAL EXPENSES when
in relation to gender dysphoria as follows:
Hormone Therapy - When in relation to gender dysphoria is covered
.
NOTE: See Gender Reassignment under ELIGIBLE MEDICAL EXPENSES on
page 17 for services and procedures that are covered.
5. Hearing Aids listed in the MEDICAL LIMITATION AND EXCLUSIONS on
page 28 is amended as follows:
REMOVE:
36. The fitting and cost of hearing aids including both surgical
implanted bone conduction hearing aids and externally worn hearing
aids regardless of the etiology of the deafness.
Hearing Aids is added to the ELIGIBLE MEDICAL EXPENSES as
follows:
Hearing Aids - Hearing Aids and Related Examinations - Hearing
examinations, hearing aids and the fitting and repair of hearing
aids. Hearing exam is limited to one (1) every Calendar year.
Hearing Aid is l imited to one (1) per ear every 36 months.
NOTE: Hearing aid batteries are not covered.
21Page Plan Amendment #1 (effective February 1, 2019)
ADO:
Hearing Aids and Related Examinations In-Network
Out-of-Network
Hearing Exam CYD and 100% plan paid CYD and 100% of U&C
Hearing Aid CYD and 100% plan paid CYD and 100% of U&C
Hearing exam is limited to one (1) every calendar year. Hearing Aid
is limited to one (1) per ear
every 36 months. NOTE: Hearing aid batteries are not covered.
6. Travel listed in the MEDICAL LIMITATION AND EXCLUSIONS on page
27 is amended as follows:
28. Travel, accommodations, and oxygen provided while traveling on
an airline. Except when approved by Utilization Management as part
of the, see Utah Travel Benefit.
7. Travel listed in the General Exclusions on page 36 is amended as
follows:
Travel - Travel or accommodation charges, whether or not
recommended by a Physician, except for ambulance charges or as
otherwise expressly included. Except when approved by Utilization
Management as part of the, see Utah Travel Benefit.
8. Utah Travel Benefit is added to Summary Plan Document, see Utah
Travel Benefit following the MANAGED CARE/UTILIZATION MANAGEMENT
PROGRAM section, page 6, Plan is amended as follows:
UTAH TRAVEL BENEFIT
The Utah Travel Benefit is established to offset the cost of travel
for patients and/or their support person or family members when
Utilization Management provides the physician and/or the Covered
Person, as an option for Tertiary Care (evaluation and/or
treatment), authorization to receive treatment at the University of
Utah Medical Center. If the Covered Person is approved for the Utah
travel benefit, the Plan will waive deductible and coinsurance
requirements for the approved treatment at a University of Utah
facility.
Tertiary Care: Highly specialized medical care usually over an
extended period of time that involves advanced and complex
procedures and treatments performed by medical specialists in
state-of-the-art facilities. Examples of tertiary care are
specialist cancer care , neurosurgery (brain surgery), burn care
and plastic surgery.
To qualify for the Utah Travel Benefit, the following must
apply:
1. Covered Person and/or their treating physician has requested a
referral lo a specific facility/provider for Tertiary Care that is
not in the primary PPO network and will require travel outside of
Nevada.
2. Utilization Management has determined that the requested
services are medically necessary and Tertiary Care cannot be
provided in the primary PPO network.
3. Utilization Management has provided the physician and/or Covered
Person, as an option, to receive Tertiary Care at the University of
Utah Medi'cal Center.
4. Covered Person has agreed to be in Case Management, and followed
by a Case Manager while in Tertiary Care.
5. Prior to travel to Utah for Tertiary Care, the Covered Person
must advise the RN Case Manager of travel to receive the
benefit.
, 3 I -, 0 g :-'
SinQle Episode of Care
Travel expenses per day, per trip $250 per patient, support
person/caregiver or parenl as defined below
Travel exoenses maximum, oer trio $2,500 oer sinale eoisode of
care
Travel exoenses calendar vear maximum $10,000
Covered Travel Expenses
1. For a covered child under the age of 19, travel expenses will be
reimbursed at $250 per person for the patient and two parents or
two legal guardians.
2. For a covered adult age 19 or older, travel expenses will be
reimbursed for the person and one person/caregiver.
3. Coverage wlll include the day prior to a scheduled service and
the day following the scheduled service not to exceed $2,500 per
Episode of Care.
After approved travel to the University of Utah Medical Center for
services, complete a Utah Travel Reimbursement Benefit Form, attach
all receipts and submit to Medlcal Management at Hometown
Health.
For more information on University of Utah health care, visit
www.healthcare.utah.edu.
9. Provider Network listed under MEDICAL BENEFIT SUMMARY on page 9
is amended as follows:
The Plan's medical PPO is Hometown Health Network (within the
service area), using all Renown Health facilities, including Renown
Regional Medical Center and Renown South Meadows, for covered
members and retirees residing in Nevada and the following
California counties: Alpine, Amador, El Dorado, Inyo, Lassen,
Modoc, Mono, Nevada, Placer, Plumas, Sierra and surrounding
counties.
Out Of Area PPO Network
For covered members and retirees residing outside of the network
service area, the covered members and retirees may gain access to a
network of preferred providers. In order to gain access to the
providers of the network (outside the service area), the covered
members and retirees must contact the benefits department in human
resources and provide the name and address of the covered members
and retirees. If available, the out of area covered members and
retirees will be assigned to the network and may use the providers
in that network to obtain preferred benefits. The out of area
covered members and retirees will be issued an ID card which
provides the online link to find and use preferred providers in the
network. If the covered members and retirees are not setup to
access the Network outside of the service area. non-network
services will be covered at the non-network benefit levels and are
subject the usual, customary and reasonable (UCR) rates.
Network Access - outside the service area
Southern Nevada -
https://www.hometownhealth.com/provider-directory-tiiter/ Select
the southern Nevada link and Hometown Health PPO.
Outside of Nevada -
https://www.hometownhealth.com/provider-directory-filter/ Select
the Out-of-State Network.
Plan Amendment #1 (effective February 1, 2019)
10. Provider Network listed under MEDICAL BENEFIT SUMMARY on page 9
is amended as follows:
Unavailable Services - When a PPO cannot be used, Non-PPO providers
will be paid at the PPO benefit level. A covered member may only
use a non-PPO specialist and obtain this benefit when the specialty
Is not represented by the PPO or is not reasonably accessible to
the patient due to geographic constraints. Pre-certification must
be obtained from UM, services will be paid as determined by the
Administrator and are subject the usual, cust.omary and reasonable
(UCR) rates.
All other Plan provisions remain unchanged so long as they are
consistent with the Amendment.
City of Reno/ p;tY ~= Fire ~ uary 1, 2019
Signature: ~~C/J~~ Printed Name: "'1cx f'\I.., C. . G f e-3 e 1/"5
e ':'.'.'.)
Title: ~ 1 Q d'5 ~R Date: 'S--_ 14 -( ?
Plan Amendment #1 (effective February 1, 2019) SI Page
City of Reno- Introduction
Contract Administrator:
City of Reno- Introduction
INTRODUCTION
This document is both the Summary Plan Description and the Plan
Document for our Preferred Provider Organization (PPO) Group Health
Plan. We recommend that you take the time to review the contents of
this document. In particular, we call the following to your
attention: • Most health claims of the Plan are handled by a
Contract Administrator. The name, address and phone number
of that company is:
Hometown Health 10315 Professional Circle
Reno, Nevada 89521 (775) 982-3232
The Contract Administrator's office should also be contacted if you
need additional information about Plan coverage for a specific
drug, treatment, procedure, preventive service, etc. No charge will
be made for the information.
• Some of the terms used in the document begin with a capital
letter. These terms have a special meaning under the Plan and are
included in the Definitions section. When reading the provisions of
this Benefit Document, it will
be helpful to refer to this section. Becoming familiar with the
terms defined there will give you a better understanding of the
benefits and provisions.
• This Plan is a self-insured program. This means that coverage is
not provided by an insurance company. Your and/or the City
contributions are used to pay claims.
Please read this document carefully. If you do not understand a
benefit, an exclusion or if you have a question, contact your
Contract Administrator’s claims office. You can find the contact
information on your Plan identification card. Failure to request
and review the terms and conditions of the Plan prior to enrollment
may not be utilized as a basis for contending lack of awareness of,
or familiarity with, or knowledge of, or being bound by the
provisions of the plan/
• Spanish Language Assistance. Si usted no entiende la información
en este documento, por favor de ponerse en
• • • •
THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT
• • • •
THE WOMEN'S HEALTH AND CANCER RIGHTS ACT Under Federal law, the
health benefits of most plans must include coverage for the
following post-mastectomy services and supplies when provided in a
manner determined in consultation between the attending physician
and the patient: (1) reconstruction of the breast on which a
mastectomy has been performed, (2) surgery and reconstruction of
the other breast to produce symmetrical appearance, (3) breast
prostheses, and (4) physical complications of all stages of
mastectomy, including lymphedemas. Plan participants must be
notified, upon enrollment and annually thereafter, of the
availability of benefits required due to the Women’s Health and
Cancer Rights Act (WHCRA).
City of Reno- Introduction
GENETIC INFORMATION AND NON-DISCRIMINATION ACT GINA (Genetic
Information and Non-Discrimination Act, effective 1/1/2010)
prohibits group health plans from collecting genetic information
and discriminating in enrollment and cost of coverage based on an
individual’s genetic information – which includes family medical
information.
MENTAL HEALTH PARITY
Pursuant to the Mental Health Parity and Addiction Equity Act of
2008, this Plan applies its terms uniformly and enforces parity
between covered health care benefits and covered mental health and
substance disorder benefits relating to financial cost sharing
restrictions and treatment duration limitations. For further
details, please contact the Plan sponsor.
NON-GRANDFATHERED PLAN This Summary Plan Description (SPD) has been
amended to comply with the requirements of the Patient Protection
and Affordable Care Act (PPACA) and the Health Care and Education
Reconciliation Act of 2010. We will provide coverage under your
benefit plan in accordance with these laws and in compliance with
applicable regulations and guidance as they are issued. We believe
that this Policy is a “non-grandfathered health plan” under the
Patient Protection and Affordable Care Act (the Affordable Care
Act). Questions regarding which protections apply to a
non-grandfathered health plan can be directed to City of Reno, the
Plan sponsor, at 775-334-2285. The Plan participant may also
contact the Employee Benefits Security administration U.S.
Department of Labor at 1-866-444-3272 or www.dol.gove/ebsa.
COBRA NOTIFICATION PROCEDURES The following procedures will apply
to Plan participants with regard to notifying the Plan of a
COBRA-related event.
A. NOTICE RESPONSIBILITIES It is a Plan participant’s
responsibility to provide the following Notices as they relate to
COBRA Continuation Coverage:
Notice of Divorce or Separation - Notice of the occurrence of a
Qualifying Event that is a divorce or legal separation of a covered
Employee from his or her spouse.
Notice of Child’s Loss of Dependent Status - Notice of a Qualifying
Event that is a child’s loss of Dependent status under the Plan
(e.g., a Dependent child reaching the maximum age limit).
Notice of a Second Qualifying Event - Notice of the occurrence of a
second Qualifying Event after a Qualified Beneficiary has become
entitled to COBRA Continuation Coverage with a maximum duration of
18 (or 29) months.
Notice Regarding Disability - Notice that: (a) a Qualified
Beneficiary entitled to receive COBRA Continuation Coverage with a
maximum duration of 18 months has been determined by the Social
Security Administration to be disabled at any time during the first
60 days of continuation coverage, or (b) a Qualified Beneficiary as
described in “(a)” has subsequently been determined by the Social
Security Administration to no longer be disabled.
Notice Regarding Address Changes - It is important that the Plan
Sponsor be kept informed of the current addresses of all Plan
participants or beneficiaries who are or may become Qualified
Beneficiaries.
B. NOTIFICATION PROCEDURES Notification must be made in accordance
with the following procedures. Any individual who is either the
covered Employee, a Qualified Beneficiary with respect to the
Qualifying Event, or any representative acting on behalf of the
covered Employee or Qualified Beneficiary may provide the Notice.
Notice by one individual shall satisfy any responsibility to
provide Notice on behalf of all related Qualified Beneficiaries
with respect to the Qualifying Event.
Form or Means of Notification - Notification of the Qualifying
Event must be provided to the Employer’s Human Resources office.
You may contact the Employer’s Human Resources office to fill out
an enrollment form stating the qualifying event.
Content - Notification must include any official documentation
showing evidence that a Qualifying Event has occurred such as a
copy of a divorce decree, a child’s birth certificate, marriage
certificate or a copy of the Social Security Administration’s
disability determination, etc.
Delivery of Notification - Notification must be received by the
Employer’s Human Resources Office.
Time Requirements for Notification - In the case of a divorce,
legal separation or a child losing dependent status, Notice must be
delivered within 60 days from the later of: (1) the date of the
Qualifying Event, (2) the date health plan coverage is lost due to
the event, or (3) the date the Qualified Beneficiary is notified of
the obligation to provide Notice through the Summary Plan
Description or the Plan Sponsor’s General COBRA Notice. If Notice
is not received within the 60- day period, COBRA Continuation
Coverage will not be available, except in the case of a loss of
coverage due to
foreign competition where a second COBRA election period may be
available – see “Effect of the Trade Act” in the COBRA Continuation
Coverage section of the Plan’s Summary Plan Description or Benefit
Document.
If an Employee or Qualified Beneficiary is determined to be
disabled under the Social Security Act, Notice must be delivered
within 60 days from the later of: (1) the date of the
determination, (2) the date of the Qualifying event, (3) the date
coverage is lost as a result of the Qualifying Event, or (4) the
date the covered Employee or Qualified Beneficiary is advised of
the Notice obligation through the SPD or the Plan Sponsor’s General
COBRA Notice. Notice must be provided within the 18-month COBRA
coverage period. Any such Qualified Beneficiary must also provide
Notice within 30 days of the date he is subsequently determined by
the Social Security Administration to no longer be disabled.
The Plan will not reject an incomplete Notice as long as the Notice
identifies the Plan, the covered Employee and Qualified
Beneficiary(ies), the Qualifying Event/disability determination and
the date on which it occurred. However, the Plan is not prevented
from rejecting an incomplete Notice if the Qualified Beneficiary
does not comply with a request by the Plan for more complete
information within a reasonable period of time following the
request.
TABLE OF CONTENTS Page
MANAGED CARE / UTILIZATION MANAGEMENT
PROGRAM................................................................
6
MEDICAL BENEFIT SUMMARY
..................................................................................................................
9
ELIGIBLE MEDICAL EXPENSES
..............................................................................................................
14
PRESCRIPTION BENEFIT SUMMARY
.....................................................................................................
31
TERMINATION OF COVERAGE
...............................................................................................................
50
EXTENSIONS OF COVERAGE
.................................................................................................................
51
CLAIMS PROCEDURES
............................................................................................................................
55
GENERAL PLAN INFORMATION
.............................................................................................................
77
COBRA CONTINUATION COVERAGE
.....................................................................................................
84
HIPAA PRIVACY & SECURITY
.................................................................................................................
90
City of Reno – Managed Care/Utilization Management Program - 6
-
MANAGED CARE/UTILIZATION MANAGEMENT PROGRAM The managed
care/utilization management program uses set criteria and protocols
to ensure that the most cost- effective preventive, acute, and
tertiary care is provided to our Members consistent with the
provision of quality care. You may be subject to a reduction in
benefits if you do not comply with this utilization management
program.
A. DELIVERY OF SERVICES
You are entitled to receive Medically Necessary medical care and
services as specified in your plan-specific summary of benefits and
this summary plan description. These include medical, surgical,
diagnostic, therapeutic, and preventive services. These are
services that are generally and customarily:
Provided in our Service Area,
Performed or ordered by a Participating Provider, and
Prior authorized by us according to our utilization management and
quality assurance protocols, if applicable.
B. SCOPE OF PROGRAMS
Under the managed care/utilization management program, a
prior-authorization is required for referrals to Physicians and
Providers for certain services. Prior-authorization means our
determination of medical necessity and benefit coverage using
utilization management and quality assurance protocols prior to the
services being rendered. All benefits listed in this summary plan
description may be subject to prior-authorization requirements and
concurrent review depending upon the circumstances associated with
the services. Please refer to your plan-specific summary of
benefits for services that require prior-authorization. The
following services are subject to a prior-authorization:
All inpatient stays and services in any facility type, including
Acute and skilled care, mental health care, drug or alcohol
detoxification, or rehabilitation (including partial or day
hospitalization services stays);
Inpatient, or same day surgical services;
Autism services;
Mental health and substance abuse services greater than 12 visits
per calendar or plan year;
Home health care;
Healthcare services and supplies including but not limited to
oxygen, oxygen-related equipment and all durable medical equipment
with a cost greater than $100;
Prosthetic and orthopedic devices with a cost greater than
$100;
Transplant services;
Services of all non-Participating Providers except that, in the
case of an emergency or for urgent care, payment for services will
be provided without a prior-authorization in accordance with the
terms of your specific Policy;
All out-of-area services, except that out-of-area services will be
provided without a prior-authorization in accordance with the terms
of your specific Policy;
Anesthesiology and physiatry services including pain
management;
Certain laboratory and diagnostic tests
Genetic counseling and testing;
City of Reno – Managed Care/Utilization Management Program - 7
-
We should be notified upon confirmation of pregnancy so we may
better manage your benefits. You must comply and cooperate with the
managed care/utilization management program. Services are subject
to all of the terms of your specific Policy.
C. APPROVAL AND PRIOR-AUTHORIZATION PROCESS
In certain cases, as set forth below, in order for a benefit to be
covered, we must approve and/or pre- authorize the service. If you
do not obtain a required prior-authorization for a service you will
not receive coverage for the service even if the service is
Medically Necessary. We use nationally recognized criteria and
internal medical policy guidelines, as reviewed periodically by our
Utilization Management and Quality Improvement Committee, as the
standard measurement tool to determine whether benefits are
approved and/or authorized.
Hospital admissions.
You are responsible for notifying us of a Hospital stay at least
five business days before elective admission to a Hospital to
ensure that it is covered. Your Physician or other Provider may
notify us but it is ultimately your responsibility to make sure we
are notified. We will review the Provider’s recommendation to
determine level of care and place of service. If we deny
authorization for Hospital admission as not covered or we determine
that the services does not meet our criteria and protocols, we will
not pay Hospital or related charges for the care that is not
Medically Necessary or does not meet our criteria or
protocols.
Inpatient and outpatient surgery.
You are responsible for making sure we are notified at least five
business days before elective inpatient or outpatient surgery is
performed to ensure that it is covered. Your Physician or other
Provider may notify us but it is ultimately your responsibility to
make sure we are notified. We will review the Physician’s
recommended course of treatment. We will pay benefits only for
inpatient/outpatient surgery that we authorize. We will not pay for
inpatient or outpatient surgery or related charges if we determine
that such charges are not a Covered Service or do not meet our
criteria and protocols.
Emergency and urgent Hospital admissions.
An emergency Hospital admission means an admission for Hospital
confinement that results from a sudden and unexpected onset of a
condition that requires medical or surgical care. In the absence of
such care, you could reasonably be expected to suffer serious
bodily Injury or death. Examples of emergency Hospital admissions
include, but are not limited to, admissions for heart attacks,
severe chest pain, burns, loss of consciousness, serious breathing
difficulties, spinal Injuries, and other Acute conditions. An
urgent Hospital admission means an admission for a medical
condition resulting from Injury or serious Illness that is less
severe than an emergency Hospital admission but requires care
within a short time, including complications of pregnancy. For an
emergency or urgent Hospital admission (including for all
complications of pregnancy), you are responsible for making sure
that we are notified within 24 hours, the next business day, or as
soon as reasonable after admission. If you are incapacitated and
you (or a friend or relative) cannot notify us within the above
stated times, we must receive notification as soon as reasonably
possible after the admission or you may be subject to reduced
benefits as provided in you specific Policy.
Healthcare services and supplies review.
A Participating Provider, including your PCP, may notify us on your
behalf to obtain prior-authorization for the services described in
Part A above (“Scope of the Program.”). Non-Participating Providers
may not know or attempt to notify us to obtain prior authorization
for services. In such a case, you must confirm that we have
pre-authorized a service in order to assure that the service is
covered. We will pay for covered health care services and supplies
only if authorized as outlined above. We will not pay for any
healthcare services or supplies that are not Covered Services or do
not meet our criteria and protocols.
D. CONCURRENT REVIEW AND CASE MANAGEMENT
After admission to a facility, we will continue to evaluate the
patient’s progress to monitor appropriate level of care and
services. If, after consulting with the Physician or a
representative of your treatment team or the Hospital case
management team, we determine a lower level of care is appropriate
or a service does not meet our criteria standards, we will not
extend continued authorization. We use nationally recognized
criteria and internal medical policy guidelines as the standard
measurement tool for this process for Acute care facilities.
We
City of Reno – Managed Care/Utilization Management Program - 8
-
also use nationally recognized criteria as the standard assessment
tool for skilled nursing facilities, rehabilitation facilities and
mental health and substance abuse facilities and programs. Case
management is a service provided by us to coordinate all services
or alternate methods of medical care or treatment that may be used
in replacement of or in combination with Hospital confinement. Our
case managers will work in coordination with the attending
Physician or other Professionals and community resources to develop
a plan of treatment per the benefit level of this Policy. Discharge
planning may be initiated at any stage of the process, and begins
immediately upon identification of post discharge needs during
prior-authorization or concurrent review.
E. RETROSPECTIVE REVIEW
We evaluate the medical records of those Members whose medical
treatment or Hospital stay was not reviewed under authorization,
prior-authorization, or concurrent review as described above. We
will pay benefits only for those days or treatment that would have
been authorized under the managed care/utilization management
program.
F. SECOND OPINIONS
We will authorize a second opinion upon your request in accordance
with the terms of your specific Policy. Examples of instances where
a second opinion may be appropriate include:
Your Physician has recommended a procedure and you are unsure
whether the procedure is necessary or reasonable;
You have questions about a diagnosis or plan of care for a
condition that threatens substantial impairment or loss of life,
limb, or bodily functions;
You are unclear about the clinical indications about your
condition;
A diagnosis is in doubt due to conflicting test results;
Your Physician is unable to diagnose your condition; and
A treatment plan in progress is not improving your medical
condition within a reasonable period of time.
City of Reno – Medical Benefit Summary - 9 -
MEDICAL BENEFIT SUMMARY
A. PROVIDER NETWORK
The Plan Sponsor has contracted with a Preferred Provider
Organization (PPO) of health care providers. When obtaining health
care services, a Covered Person has a choice of using providers who
are participating in the PPO network or any other Covered Providers
of his/her choice (Non-PPO providers). PPO providers have agreed to
provide services to Covered Persons at negotiated discount fees to
Plan participants. When a Covered Person uses a PPO provider
his/her out-of-pocket costs may be reduced because he will not be
billed for expenses in excess of those negotiated rates. PPO
providers have agreed to accept the Plan’s benefit payment for
eligible expenses, plus any applicable deductible, copayments or
coinsurance you are responsible for paying, as payment in full. The
Plan may also include other benefit incentives to encourage Covered
Persons to use PPO providers whenever possible. Non-PPO providers
have no agreements with the Plan and are generally free to set
their own charges for services or supplies. The Non-PPO provider’s
charge is subject to the Plan’s Usual and Customary (U&C)
allowable. The U&C allowable for Non-PPO provider’s charges is
the PPO negotiated rate. The Covered Person will be responsible for
any amounts in excess of the U&C (called balance billing). You
can avoid potential balance billing by using a PPO provider. The
Plan’s medical PPO is Hometown Health Network, using all Renown
Health facilities, including Renown Regional Medical Center and
Renown South Meadows, for employees and retirees residing in Nevada
and the following California counties: Alpine, Amador, El Dorado,
Inyo, Lassen, Modoc, Mono, Nevada, Placer, Plumas, Sierra and
surrounding counties. For employees and retirees residing outside
of the service area or for emergency care outside of the service
area, your PPO network is PHCS Network. PPO providers are added and
dropped from the PPO networks periodically throughout the year and
it is your responsibility to verify if the provider is in the PPO
network BEFORE seeking services from a PPO provider. Listing of
hospitals, physicians, ambulatory surgery centers, laboratory,
radiology and other medical providers can be found at Hometown
Health’s or PHCS Network’s website. You can search for providers
and print the PPO directory from the website or you may call a
customer service representative. Contract information is
below.
HOMETOWN HEALTH PROVIDERS NETWORK
www.hometownhealth.com
www.multiplan.com
When a Non-PPO provider is used because of the below circumstances,
then the Non-PPO’s billed charges will be subject to the Usual and
Customary allowable defined in the Definitions. Emergency Care – In
the event a Covered Person requires care for a Medical Emergency,
as defined in the Definitions, and is transported to a Non-PPO
provider, such Non-PPO billed charges will be subject to Usual
and
Customary instead of the PPO allowable. Unavailable Services - If a
Covered Person requires services from a Non-PPO provider because
the necessary
specialty is not represented in the PPO network and
Pre-certification has been obtained from UM, then the Non- PPO’s
billed charges will be subject to Usual and Customary instead of
the PPO allowable.
Ancillary Services - Services of a Non-PPO ancillary provider (i.e.
emergency room Physician, urgent care
Physician, radiologist, pathologist, on-call Physician) will be
covered at the PPO benefit levels if such services are received
while a Covered Person is being treated in the emergency room of a
PPO hospital, PPO Urgent Care Facility, PPO Ambulatory Surgery
Center or confined in a PPO hospital facility.
B. SCHEDULE OF MEDICAL BENEFITS
The benefits outlined in the Benefit Summary Table are not a
complete listing of the medical services covered under this benefit
plan. Benefits for services not listed can be found throughout the
plan document. Copayments and/or coinsurance for services not shown
in the Benefit Summary Table are determined by the location in
which services are provided (such as: emergency rooms, urgent care
centers or physicians’ offices). The copayment and/or coinsurance
amounts listed in the Benefits Summary Table are applicable for
covered services received as described throughout the plan
document. All charges associated with non-covered services or
denied claims are the member’s responsibility.
NOTE: The Plan pays 20% of covered charges after the deductible for
all retirees who are eligible for but not enrolled in Medicare Part
A and Part B.
Benefit Summary Table Benefit Category In-Network
Out-of-Network
Active Employees, Retirees Enrolled for Medicare and Retirees not
Yet Medicare-Eligible
Maximum Plan Benefit unlimited
Maximum annual benefit unlimited
Prescription Drugs – Single / Family $3,850 / $7,700
During any calendar year, individuals are responsible for paying
deductible, copayments and coinsurance up to the single, annual
out-of-pocket maximum unless coverage is extended to qualified
dependents and the family annual out-of-pocket maximum has been
satisfied.
Deductibles –
Medical - Single / Family $300 / $600 $900 / $1800
Medical deductible applies to all medical services noted with CYD
(calendar year deductible) under member responsibility... Medical
deductible limits must be met every calendar year before benefits
are payable for medical services other than Primary Care, Specialty
Care or Wellness office visits. Individuals within a family must
satisfy the single medical deductible limit every calendar year
before medical benefits are payable for services other than Primary
Care, Specialty Care or Wellness office visits. However, once the
family as a whole has satisfied the family deductible within the
calendar year, no further medical deductible limits need to be
satisfied except for benefit-specific deductibles.
Physician Office Visits –
$20 / $50 copay / visit
$0 / $0 copay / visit
Not Covered
One wellness visit per year is covered for member older than two.
All necessary wellness visits are covered for children less than
two years of age.
City of Reno – Medical Benefit Summary - 11 -
Urgent Care and Emergency Services –
Urgent Care Center Services $50 copay / visit 40% after ded.
Emergency Room Services CYD and $250 copay / visit CYD and
$250
copay / visit
Copayments for emergency room services are waived if the member is
admitted to the hospital
Ambulance (ground) CYD and $200 copay / trip 40% after ded
Ambulance (air and water) CYD and $200 copay / trip 40% after
ded
Imaging and Diagnostic Testing –
Radiological/Cardiological/Neurological
Computer Tomography (CT) scan CYD and $200 copay / visit 40% after
ded
Magnetic Resonance Imaging (MRI) CYD and $200 copay / visit 40%
after ded
Positron Emission Tomography (PET) scan CYD and $200 copay / visit
40% after ded
All other X-ray services CYD and $30 copay / visit 40% after
ded
Laboratory Services –
CYD and $30 copay 40% after ded
NOTE: The Plan pays 20% of covered charges after the deductible for
all retirees who are eligible for but not enrolled in Medicare Part
A and Part B.
Benefit Summary Table (continued)
Benefit Category In-Network Out-of-Network
Wellness and Preventive Services–
(STI) HIV counseling and testing Breastfeeding support, supplies
and counseling Screening for interpersonal and domestic
violence Contraceptives and Counseling for FDA
approved in office including injections, implants, and
contraceptive devices not covered under pharmacy benefits
Screening for Gestational Diabetes High-risk human papillomavirus
(HPV) testing in
women Certain other Preventive Services as defined by this
Plan.
Primary / Specialty care physician
Hospital Inpatient Services –
CYD and $250 / admit
Outpatient observation CYD and $ 50 /
admit 40% after ded.
Skilled nursing facility Limited to 30- days per calendar
year
CYD and $0/ admit
CYD and $0 / admit
City of Reno – Medical Benefit Summary - 12 -
NOTE: The Plan pays 20% of covered charges after the deductible for
all retirees who are eligible for but not enrolled in Medicare Part
A and Part B.
Benefit Summary Table (continued) Benefit Category In-Network
Out-of-Network
Outpatient Therapy and Rehabilitation Services –
Speech therapy Occupational therapy Physical therapy
Limited to 20 aggregate visits per therapy type per member per
calendar year
$20 copay / visit 40% after ded
Wound therapy Chemotherapy Infusion therapy
Services provided in a physician office
$15 copay/visit 40% after ded
Chemotherapy Infusion therapy Radiation therapy
Services provided in an outpatient hospital setting
$15 copay / visit 40% after ded
Cardiac and pulmonary rehabilitation
$15 copay/ visit 40% after ded
Cardiac and Pulmonary Rehabilitation services require prior
authorization
Mental Health –
Inpatient Services for mental illnesses (including but not limited
to semi- private room and meals)
CYD and $0 copay / per day
40% after ded
Partial hospitalization Services for mental illnesses CYD and $0
copay/ day 40% after ded
Outpatient visit-mental health
Services for mental health $20 copay / visit 40% after ded
Inpatient mental health, substance abuse and partial
hospitalization require prior authorization. Outpatient mental
health, substance abuse, and counseling visits for more than 12
visits per calendar year, require prior authorization for benefit
coverage to be made available.
Surgical Services –
Performed in physician’s office
Primary / Specialty care physician $20 / $50 copay / visit 40%
after ded
Performed in outpatient facility or same day surgery facility
Includes physician services and facility charges
CYD and $250 copay 40% after ded
Surgical removal of lipomas
Plus the PCP, Specialist office visit copay or surgery facility
copayment as applicable
$75 copay / visit 40% after ded
Medical Supplies –
Durable medical equipment (purchase and rental)
CYD and $0 copay per item CYD and $0 copay per item
/ per month
Ostomy care supplies (30-day supply)
CYD and $0 copay
CYD and $0 copay per 30
day supply 40% after ded.
City of Reno – Medical Benefit Summary - 13 -
NOTE: The Plan pays 20% of covered charges after the deductible for
all retirees who are eligible for but not enrolled in Medicare Part
A and Part B.
Benefit Summary Table (continued) Benefit Category In-Network
Out-of-Network
Alcohol and Substance-Abuse Treatment –
40% after ded.
by site of service) 40% after ded.
Outpatient treatment $20 copay / visit
Inpatient mental health, substance abuse and partial
hospitalization require prior authorization. Outpatient mental
health, substance abuse, and counseling visits for more than 12
visits per calendar year, require prior authorization for benefit
coverage.
Prescription Drug Program –
$1,000 maximum benefit per calendar year
$30 copay / visit 40% after ded.
Spinal manipulation Maximum benefit: limited to 30 visits per
member per calendar year
$50 copay / visit 40% after ded.
Home health care Maximum benefit: limited to 40 visits per member
per calendar year.
$20 copay / visit 40% after ded.
Hospice
$0 copay 40% after ded.
Kidney dialysis and associated services
$50 copay / visit 40% after ded.
Infertility services Copayment varies by site of
service 40% after ded.
Genetic counseling and testing
Temporomandibular Joint Disorder (TMJ)
Immunosuppressive Medications
service 40% after ded.
Some medications, injections, and infusion drugs require prior
authorization.
THIS IS A SUMMARY ONLY. SEE THE ELIGIBLE MEDICAL EXPENSES AND
MEDICAL LIMITATIONS AND EXCLUSIONS SECTIONS FOR MORE
INFORMATION.
City of Reno – Eligible Medical Expenses - 14 -
ELIGIBLE MEDICAL EXPENSES All medical care must be received from or
ordered from a Covered Provider. Except as otherwise noted below or
in the Medical Schedule of Benefits, eligible medical expenses are
the charges for the items listed below and which are incurred by a
Covered Person – subject to the Definitions, Limitations and
Exclusions and all other provisions of the Plan. In general,
services and supplies must be approved by a Physician or other
appropriate Covered Provider and must be Medically Necessary for
the care and treatment of a covered Illness, Injury, Pregnancy or
other covered health care condition. For benefit purposes, medical
expenses are deemed to be incurred on: the date delivery is made;
or the actual date a service is rendered.
A. PROFESSIONAL SERVICES
1. Alcohol and substance abuse services (inpatient and
outpatient)
Covered benefits for inpatient and outpatient alcohol and substance
abuse services will be provided under the same provisions as
medical and surgical benefits, with no additional financial or
treatment limitations.
a. Covered services are limited to diagnosis, medical treatment,
and medical aspects of rehabilitation. Non-medical ancillary
services such as Narcotics Anonymous or Alcoholics Anonymous will
not be covered. Covered services include:
i. Treatment for withdrawal from the physiological effects of
Alcohol or Substance Abuse
ii. Inpatient treatment and
iii. Outpatient counseling, including group and family
counseling
b. Benefits for covered services will be paid in the same manner as
benefits for those services for any other illness covered by this
SPD provided that the member is entitled to these benefits and
treatment is received in:
i. A facility for the treatment of abuse of alcohol or drugs which
is certified by the Health Division of the Department of Human
Resources
ii. A hospital or other medical facility or facility which is
licensed by the Health Division of the Department of Human
Resources, accredited by the Joint Commission on Accreditation of
Healthcare Organizations and provides a program for the treatment
of abuse of alcohol or drugs as part of its accredited
activities
2. Alternative medicine (see homeopathic and acupuncture
care)
3. Ambulance services
a. Provided in an emergency
b. Provided in non-emergency setting when ordered by member's PCP
and prior-authorized by Hometown Health
4. Autism Spectrum Disorder
Coverage is provided for Medically Necessary screening for and
diagnosis of autism spectrum disorders, and for the Medically
Necessary treatment of autism spectrum disorders to individuals
under the age of 18 (or under the age of 22, for individuals
enrolled in high school).
“Autism spectrum disorder” means a neurobiological medical
condition including, without limitation, autistic disorder,
Asperger’s Disorder, and Pervasive Developmental Autism Disorder
Not Otherwise Specified. Treatment must be identified in a
treatment plan prescribed by a licensed Physician, or psychologist
and may be developed pursuant to a comprehensive evaluation in
coordination with a licensed behavior analyst. Subject to the other
requirements of this plan, treatment may include Medically
Necessary habilitative or rehabilitative care, prescription care,
psychiatric care, psychological care, behavior therapy, or
therapeutic care that is:
Prescribed for a person diagnosed with an autism spectrum disorder
by a licensed Physician or licensed psychologist; and
Provided to a person diagnosed with an autism spectrum disorder by
a licensed Physician, licensed psychologist, licensed behavior
analyst, licensed assistant behavior analyst, certified autism
behavior
City of Reno – Eligible Medical Expenses - 15 -
interventionist or other provider that is supervised by the
licensed Physician, psychologist, or behavior analyst.
Coverage is subject to a maximum benefit of 515 hours per calendar
or plan year for applied behavioral analysis treatment. Services
that are delivered subject to this specific benefit for services
for Autism Spectrum Disorders do require prior authorization.
Coverage is not provided for reimbursements to an early
intervention agency or school for services delivered through early
intervention or school services.
5. Blood services for surgery
6. Chemotherapy
The financial limits applicable to oral Chemotherapy will be no
less favorable than the financial limits applicable to Chemotherapy
administered by injection or intravenously
7. Clinical trials
The routine medical treatment costs, including all items and
services that are otherwise generally available to Hometown Health
members, received as part of a clinical trial or study is covered
if:
a. The medical treatment is provided in a Phase II, Phase III or
Phase IV study or clinical trial for the treatment of cancer or
chronic fatigue syndrome.
b. The clinical trial or study is approved by:
i. An agency of the National Institutes of Health
ii. A cooperative group, a network of facilities that collaborate
on research projects and has established a peer review program
approved by the National Institutes of Health
iii. The Food and Drug Administration (FDA) as an application for a
new investigational drug
iv. The United States Department of Veterans Affairs
v. The United States Department of Defense
vi. The medical treatment is provided by a provider of health care
and the facility and personnel have the experience and training to
provide the treatment in a capable manner
vii. There is no medical treatment available which is considered a
more appropriate alternative medical treatment than the medical
treatment provided in the clinical trial or study
viii. There is a reasonable expectation based on clinical data that
the medical treatment provided in the clinical trial or study will
be at least as effective as any other medical treatment
ix. The clinical trial or study is conducted in Nevada, and
x. The member has signed, before his/her participation in the
clinical trial or study, a statement of consent indicating that
he/she has been informed of, without limitation:
The procedure to be undertaken;
Alternative methods of treatment; and
The risks associated with participation in the clinical trial or
study, including, without limitation, the general nature and extent
of such risks.
c. Medical treatment is limited to:
i. Coverage for any drug or device that is approved for sale by the
Food and Drug Administration (FDA) without regard to whether the
approved drug or device has been approved for use in the medical
treatment of the member
ii. The cost of any reasonable necessary health care services that
are required as a result of the medical treatment provided in the
clinical trial or study or as a result of any complication arising
out of the medical treatment provided in the clinical trial or
study, to the extent that such health care services would otherwise
be covered under Hometown Health
City of Reno – Eligible Medical Expenses - 16 -
iii. The initial consultation to determine whether the member is
eligible to participate in the clinical trial or study
iv. Health care services required for the clinically appropriate
monitoring of the member during the clinical trial or study
d. In addition, if a member participates in an approved clinical
trial with respect to the treatment of cancer or another
life-threatening disease or condition, the Plan will not deny (or
limit or impose additional conditions on) the coverage of routine
patient costs for items and services furnished in connection with
participation in the trial and will not discriminate against the
member on the basis of the individual’s participation in the trial.
For these purposes, an “approved clinical trial” means a phase I,
II, III or IV clinical trial that is conducted in relation to the
prevention, detection, or treatment of cancer or other
life-threatening disease or condition, and is either (i) a
federally funded or approved study or investigation, (ii) a study
or investigation conducted under an investigational new drug
application reviewed by the Food and Drug Administration, or (iii)
a study or investigation that is a drug trial exempt from having
such an investigational new drug application.
A member is eligible to participate in an approved clinical trial
according to the trial protocol with respect to the treatment of
cancer or another life-threatening disease or condition; if either:
(1) the referring health care professional is a Participating
Provider and has concluded that the individual’s participation in
such trial would be appropriate; or (2) the member provides medical
and scientific information establishing that the individual’s
participation in such trial would be appropriate.
For questions about the coverage for clinical trials provision,
including complaints regarding compliance with the statutory
provision by health insurance issuers, contact the Nevada Division
of Insurance at-1-888-872-3234 or the Centers for Medicare &
Medicaid Services, Center for Consumer Information and Insurance
Oversight at 1-888-393-2789.
8. Colorectal screening
9. Diabetic services for type 1, 2 and gestational diabetes
a. Management and treatment of diabetes including infusion pumps
and related supplies, medication, equipment, supplies and
appliances for the treatment of diabetes
b. Self-management of diabetes, including:
i. Training and education provided after a member is initially
diagnosed with diabetes for the care and management of diabetes,
including, counseling in nutrition and the proper use of equipment
and supplies for the treatment of diabetes
ii. Training and education which is necessary as a result of a
subsequent diagnosis that indicates a significant change in the
symptoms or condition which requires modification of his/her
program of self-management of diabetes, and
iii. Training and education which is necessary because of the
development of new techniques and treatment for diabetes
10. Durable medical equipment (DME)
a. The purchase, rental, repair or maintenance of DME for other
than kidney dialysis
b. DME includes, but not limited to:
i. Oxygen equipment (all oxygen and oxygen related equipment,
except for oxygen while traveling on an airline)
ii. Wheelchairs
iii. Hospital beds
iv. Glucose monitors
v. Warning or monitoring devices for infants (defined as a child 24
months old or less) suffering from recurrent apnea (limited to 90
days)
Hometown Health’s coverage will be based on an amount equal to the
generally accepted cost of DME that provides the necessary level of
care at the lowest cost. In determining Hometown Health's
liability, Hometown Health will be guided by nationally established
standards of the rental or purchase of such equipment.
City of Reno – Eligible Medical Expenses - 17 -
11. Family planning
12. Food products
Special food products for the treatment of inherited metabolic
diseases characterized by deficient metabolism, or malabsorption
originated from congenital defects or defects arising shortly after
birth, of amino acid, organic acid, carbohydrate or fat.
13. Gender Reassignment – Gender reassignment surgery consisting of
any combination of the following
when the following criteria is met:
a. Requirements for mastectomy for female-to-male patients:
Single letter of referral from a qualified mental health
professional; and
Persistent, well-documented gender dysphoria (see Appendix);
and
Capacity to make a fully informed decision and to consent for
treatment; and
Age of majority (18 years of age or older); and
If significant medical or mental health concerns are present, they
must be reasonably well controlled.
b. Requirements for gonadectomy (hysterectomy and oophorectomy in
female-to-male and orchiectomy in male-to-female):
Two referral letters from qualified mental health professionals,
one in a purely evaluative role (see Appendix);
Persistent, well-documented gender dysphoria (see Appendix);
and
Capacity to make a fully informed decision and to consent for
treatment; and
Age of majority (18 years of age or older); and
If significant medical or mental health concerns are present, they
must be reasonably well controlled; and
Twelve months of continuous hormone therapy as appropriate to the
member’s gender goals (unless the member has a medical
contraindication or is otherwise unable or unwilling to take
hormones).
c. Requirements for genital reconstructive surgery (i.e.
vaginectomy, urethroplasty, metoidioplasty, phalloplasty,
scrotoplasty, and placement of a testicular prothesis and erectile
prosthesis in female to male, penectomy, vaginoplasty, labiaplasty,
and clitoroplasty in male to female):
Two referral letters from qualified mental health professionals,
one in a purely evaluative role (see Appendix);
Persistent, well-documented gender dysphoria (see Appendix);
and
Capacity to make a fully informed decision and to consent for
treatment; and
Age of majority (18 years of age or older); and
If significant medical or mental health concerns are present, they
must be reasonably well controlled; and
Twelve months of continuous hormone therapy as appropriate to the
member’s gender goals (unless the member has a medical
contraindication or is otherwise unable or unwilling to take
hormones); and
Twelve months of living in a gender role that is congruent with
their gender identity (real life experience).
NOTE: See Gender Reassignment under MEDICAL LIMITATIONS AND
EXCLUSIONS for
services and procedures that are not covered.
14. Genetic counseling/testing
a. Genetic Testing may only be done after consultation with an
appropriately certified Genetic Counselor or as approved by
Hometown Health medical director.
b. Genetic counseling will be covered in connection with pregnancy
management in the following circumstances:
City of Reno – Eligible Medical Expenses - 18 -
i. Parents of a child born with a genetic disorder, birth defect,
inborn error of metabolism, or chromosome abnormality
ii. Parents of a child with mental retardation, autism, Down
syndrome, trisomy conditions, or fragile X syndrome
iii. Pregnant women who, based on prenatal ultrasound tests or an
abnormal multiple marker screening test, maternal serum
alpha-fetoprotein (AFP) test, test for sickle cell anemia, or tests
for other genetic abnormalities, have been told their pregnancy may
be at increased risk for complications or birth defects
iv. Parents affected with an autosomal dominant disorder,
contemplating pregnancy
v. Mother is a known or presumed carrier of an X-linked recessive
disorder
15. Home health care
a. House Calls - provided by a member's PCP as the nature of the
illness dictates
b. Home Care - provided by a home health agency. Such care will not
be available if it is substantially or primarily for a member's
convenience. Home care will be provided in the home only on a
part-time and temporary basis. Certified Nurse’s Aides and Home
Health Aides are not covered.
c. Home health care does not include over-the-counter medical
equipment, over-the-counter supplies, or any prescription drugs.
These benefits are only available to the extent that they are
covered elsewhere in this SPD or Pharmacy Rider.
16. Hospice services
Hospice care services for members with a life expectancy of six (6)
months or 185 days or less as certified by his or her PCP. (limited
to a lifetime benefit maximum of 185 days).
a. Intermittent home health care
b. Outpatient counseling of the member and his or her immediate
family. Counseling must be provided by:
i. A licensed psychiatrist;
ii. A licensed psychologist; or
iii. A licensed social worker.
c. Respite care provides nursing care for a maximum of three,
48-hour periods in the hospice benefit period. Inpatient respite
care will be provided only when Hometown Health determines that
home respite care is not appropriate or practical.
17. Homeopathic and acupuncture care
Office visits for homeopathic and acupuncture services, (limited to
$1,000 per calendar year).
18. Infertility services
Medically Necessary services to diagnose problems of infertility
are covered. The following services are not covered:
All other costs incurred for reproduction by artificial means or
assisted reproductive technology (such as in-vitro fertilization,
artificial insemination, or embryo transplants) including services,
tests, supplies, devices, or drugs intended to produce a
pregnancy;
The promotion of fertility including, but not limited to, fertility
testing (except as otherwise covered and described above); serial
ultrasounds; services to reverse voluntary surgically-induced
infertility; reversal of surgical sterilization; any service,
supply, or drug used in conjunction with or for the purpose of an
artificially induced pregnancy, artificial insemination (including
test-tube fertilization); the cost of donor sperm or eggs; in-vitro
fertilization and embryo transfer or any artificial reproduction
technology or the freezing of sperm or eggs or storage costs for
frozen sperm, eggs, or embryos; maternity services related to a
Member serving in the capacity of a surrogate mother or
prescription (infertility) drugs; or GIFT or ZIFT procedures, low
tubal transfers, or donor egg retrieval;
City of Reno – Eligible Medical Expenses - 19 -
Any services related to a Member serving in the capacity of a
surrogate mother, including, but not limited to, determining,
evaluating, or enhancing the physical or psychological readiness
for pregnancy, procedures to improve the Member’s ability to become
pregnant or to carry a pregnancy to term, or maternity services;
and
Any payment made by or on behalf of a Member who is contemplating
or has entered into a contract for surrogacy to a Provider or
individual related to any services potentially included in the
scope of surrogacy services described above
19. Kidney dialysis services
Kidney dialysis services and related therapeutic services and
supplies, (e.g., epogen) to the extent these are not covered by the
Medicare program.
20. Lab and diagnostic services determined to be medically
necessary
X-ray and laboratory procedures, services and materials, including,
but not limited to:
Diagnostic X-rays (Radiological/Cardiology
related/Neurological)
21. Mastectomy reconstructive surgery
Breast reconstructive surgery and the internal or external
prosthetic devices for members who received mastectomy surgery as a
covered benefit while a member of this group medical plan. External
prosthesis are limited to the billed charges or the allowed charges
set by the Centers for Medicare and Medicaid Services (CMS),
whichever is less.
a. If reconstructive surgery is begun within 3 years after the
mastectomy, coverage will be extended to the member or former
member for all eligible charges for such reconstructive surgery as
would have been provided at the time of the mastectomy. If a
covered mastectomy is performed while a member of Hometown Health
and the mastectomy is paid for by Hometown Health, subject to all
the terms and conditions of this SPD, Hometown Health will also
provide coverage for: (a) reconstruction of the breast on which the
mastectomy has been performed; (b) surgery and reconstruction of
the other breast to produce a symmetrical structure; and (c)
prostheses; and (d) physical complications for all stages of
mastectomy, including lymphedemas.
b. If reconstructive surgery is begun within 3 years after a
mastectomy, the amount of the benefits for that surgery must equal
the amounts provided for in the policy at the time of the
mastectomy. If the surgery is begun more than 3 years after the
mastectomy, the benefits provided are subject to all the terms,
conditions and exclusions contained in the policy at the time of
reconstructive surgery. No benefits will be paid for reconstructive
surgery or any complications resulting from reconstructive surgery
more than 3 years after the mastectomy if the patient is no longer
a member of this plan.
22. Maternity care and care of newborns
Medically Necessary services for pregnant Members are covered,
including prenatal and postpartum care, related delivery room an
ancillary services and newborn care. Newborn care includes care and
treatment of medically diagnosed congenital defects, birth
abnormalities, or prematurity and transportation costs of newborn
to and from the nearest facility staffed and equipped to treat the
newborn’s condition. Notwithstanding anything in this SPD to the
contrary, for Non-Grandfathered Plans, a Member does not need prior
authorization from us or from any other person in order to obtain
access to obstetrical or gynecological care from a professional in
our Network who specializes in obstetrics or gynecology. The
Professional, however, may be required to comply with certain
procedures, including obtaining prior authorization for certain
services, following a pre-approved treatment plan, or procedures
from making referrals. For a list of participating Professionals
who specialize in obstetrics or gynecology, go to
www.hometownhealth.com or contact or customer services.
Notwithstanding anything in this SPD to the contrary, for
Non-Grandfathered Plans, in the case of a person who has a child
enrolled in coverage, we will permit such person to designate any
pediatrician if such pediatrician
City of Reno – Eligible Medical Expenses - 20 -
• Amniocentesis to extend that it is performed to determine the sex
of the child
• Non-newborn circumcisions after eight weeks of age unless
Medically necessary and prior- authorized by the Contract
administrator.
23. Medical care and preventive services:
Office visits and consultations
Periodic physical examinations and routine immunizations in
accordance with Hometown Health’s Medical Practice Guidelines
Routine gynecologic examination (1 per calendar year), including
annual cytologic screening test (Pap smear) for women; pelvic
examination; urinalysis and breast examination
Screening mammograms including an initial baseline mammogram for
female members 35 - 39 and annually for women 40 years of age or
older
Well-baby care, including immunizations in accordance with the
American Academy of Pediatrics and other federal agencies
Allergy testing and serum
Influenza, Pneumovax, Haemophilus influenza B, Hepatitis A,
Hepatitis B, Hepatitis C, Rubella and Tetanus immunizations.
Hearing and vision screening for children through age 17 to
determine the need for hearing and vision correction
Services recommended and endorsed through the PPACA legislation and
recommendations of the agencies named within
24. Mental health services
Covered benefits for general mental health (including services
related to the treatment of Attention Deficit Disorder (ADD &
ADHD)) and severe mental illness will be provided under the same
provisions as medical and surgical benefits, with no additional
financial or treatment limitations.
25. Oral surgery, dental services, and temporomandibular joint
disorder (TMJ)
Oral surgery procedures will be provided (inpatient or outpatient)
related to the following:
a. Accidental injury to the jaw bones or surrounding tissues when
the injury occurs and the repair takes place while a member of the
plan
Services must commence within 90 days after the accidental injury
(services that commence after 90 days are not covered).
b. Treatment for tumors and cysts requiring pathological
examination of the jaws, cheeks, lips, tongue, and roof and floor
of the mouth
c. Non-dental surgical procedures and hospitalization required for
newly born and children placed for adoption or newly adopted to
treat congenital defects, such as cleft lip and cleft palate
d. Medical or surgical procedures occurring within or adjacent to
the oral cavity or sinuses including treatment of fractures
e. TMJ services are covered only when the required services are not
recognized dental procedures.
f. Dental general anesthesia for a dependent child when services
are rendered in a hospital or outpatient surgical facility, when
enrolled dependent child is being referred because, in the opinion
of the dentist, the child:
i. Is under 18 and has a physical, mental or medically compromising
condition
ii. Is under 18 and has dental needs for which local anesthesia is
ineffective because of an acute infection, an anatomic anomaly or
an allergy, or
iii. Is under age 5
City of Reno – Eligible Medical Expenses - 21 -
g. Prior-authorization is required for dental general anesthesia in
a hospital or outpatient surgical facility. Dental anesthesiology
services are covered only for procedures performed by a qualified
specialist in pediatric dentistry, a dentist educationally
qualified in a recognized dental specialty for which hospital
privileges are granted or who is certified by virtue of completion
of an accredited program of post-graduate hospital training to be
granted hospital privileges.
26. Orthopedic devices and prosthetic devices
a. Orthopedic devices are limited to braces for problems requiring
complete immobilization or for support, or if the braces are custom
fitted or have rigid bar or flat steel supports and stays, splints,
devices for congenital disorders, post and pre-operative
devices.
b. Prosthetic devices, approved by Centers for Medicare &
Medicaid, required to substitute for missing or non-functioning
body parts or organs are limited to:
i. Devices provided in connection to an illness or injury, which
occurred subsequent to a member’s effective date of coverage under
this SPD
ii. Adjustment of initial prosthetic device
iii. Repair and replacement of prosthetic devices are not covered
except in limited situations involving mastectomy reconstructive
surgery
iv. The first pair of eyeglasses or contact lenses (up to the
Medicare allowable) immediately following cataract surgery
27. Ostomy care supplies
Care and supplies provided to the member after colon, ileum and/or
bladder surgery to carry on normal activities with a minimum of
inconvenience.
28. Outpatient observation (in facility)
Services furnished on a hospital’s premises, including use of a bed
and periodic monitoring by a hospital’s nursing or other staff,
which are reasonable and necessary to evaluate an outpatient’s
condition or determine the need for a possible admission to the
hospital. If the hospital intends to keep a patient in observation
status for more than 24-48 hours, observation status will become an
inpatient admission for administration of benefits.
29. Podiatry services
Podiatry services for the treatment of acute conditions of the foot
such as infections, inflammation, or injury and other foot care,
which is disease related.
30. Prescription Drugs
Medicines that are dispensed and administered to a Covered Person
during an Inpatient confinement, during a Physician's office visit,
or as part of a home health care or hospice care program. Other
Outpatient drugs (i.e., pharmacy purchases) are covered through a
separate program. See the Medical Benefit Summary for more
information.
31. Preventive Services
Covered preventive services include but are not limited to: i.
Periodic physical examinations and routine immunizations; ii.
Routine gynecologic examination (one per calendar year), including
annual cytologic
screening test (Pap smear) for women 18 years of age or older,
pelvic examination, urinalysis, and breast examination;
iii. Screening mammograms including an initial baseline mammogram
for female Members 35–39 and annually for women 40 years of age or
older;
iv. Well-baby care, including immunizations in accordance with the
American Academy of Pediatrics and other federal agencies;
v. Prostate and colorectal cancer screening in accordance
with:
The guidelines concerning such screening that are published by the
American Cancer Society or
Other guidelines or reports concerning such screening that are
published by nationally recognized professional organizations and
that include current or prevailing supporting scientific
data.
City of Reno – Eligible Medical Expenses - 22 -
vi. Influenza, pneumovax, haemophilus influenza B, hepatitis A,
hepatitis B, hepatitis C, rubella, and tetanus immunizations;
and
vii. Hearing and vision screening for children through age 17 to
determine the need for hearing and vision correction.
Notwithstanding anything to the contrary in this EOC,
Non-Grandfathered Plans will cover the following services without
any Member cost-sharing requirements if such services are provided
by a Participating Provider:
viii. Evidence-based items or services that have in effect a rating
of “A” or “B” in the current recommendations of the United States
Preventive Services Task Force, provided that, with regard to
breast cancer screening, mammography, and prevention, the current
recommendations of the United States Preventive Services Task Force
will be the most current other than those issued in or around
November 2009;
ix. Immunizations that have in effect a recommendation from the
Advisory Committee on Immunization Practices of the Centers for
Disease Control and Prevention with respect to the individual
involved;
x. With respect to infants, children, and adolescents,
evidence-informed preventive care and screenings provided for in
comprehensive guidelines supported by the Health Resources and
Services Administration of the U.S. Department of Health and Human
Services; and
xi. With respect to women, such additional preventive care and
screenings not described under this section as provided for in
comprehensive guidelines supported by the Health Resources and
Services Administration of the U.S. Department of Health and Human
Services.
32. Radiation therapy
33. Second opinions
34. Short-term rehabilitative therapy
a. Outpatient short-term speech, physical, and occupational
rehabilitative therapy for acute conditions which are subject to
significant clinical improvement over a three-month (90 day) period
from the date outpatient therapy commences (limited to 20 visits
each for speech, physical, and occupational therapy per calendar
year)
b. Outpatient services for cardiac rehabilitation and pulmonary
rehabilitation (limited to 40 visits/sessions per calendar year for
each type of therapy)
c. Inpatient short term rehabilitative services are limited to
treatment of conditions which are subject to significant clinical
improvement over a continuous 30 day period from the date inpatient
therapy commences in a distinct rehabilitation unit of a hospital,
skilled nursing facility or other facility approved by Hometown
Health. (limited to 30 days per calendar year)
35. Skin lesions
36. Spinal treatment (non-surgical)
Spinal manipulations and adjustments (limited to 30 visits per
member per calendar year)
37. Transplant services
Organ transplants when the member is the organ recipient: cornea,
artery or vein, kidney, joint, heart valve, implantable prosthetic
lenses (in connection with cataracts), prosthetic bypass or
replacement vessels, bone marrow, heart, lungs
City of Reno – Eligible Medical Expenses - 23 -
a. Related services limited to: tests necessary to identify an
organ donor, the reasonable expense of acquiring the donor organ,
transportation of the donor organ (but not the donor), and life
support where such support is for the sole purpose of removing the
donor organ, follow-up care and immunosuppressive
medications.
b. Immunosuppressive medications are covered after an organ
transplant operation.
B. HOSPITAL, SKILLED NURSING AND SERVICES IN AN OUTPATIENT SURGICAL
CENTER
1. Inpatient hospital services include, but are not limited
to:
2. Semi-private room and board (private room when medically
necessary)
3. General nursing care facilities, services, and supplies on an
inpatient basis, including: meals and special diets when medically
necessary, use of operating room and related facilities, use of
intensive care or cardiac care units and related services, X-ray
services, laboratory and other diagnostic tests, non-experimental
and non-investigational prescription drugs, biologicals, anesthesia
and oxygen services, blood and blood plasma and its administration,
special duty nursing when medically necessary, radiation therapy,
inhalation therapy, and chemotherapy (including chemotherapy
drugs)
4. Inpatient care short-term rehabilitative services are limited to
treatment of conditions which are subject to significant clinical
improvement over a continuous 30 day period from the date inpatient
therapy commences in a distinct rehabilitation unit of a hospital,
skilled nursing facility or other facility approved by Hometown
Health. (Inpatient short-term rehabilitative services are limited
to 30 days per calendar year).
5. Surgical and obstetrical procedures, including the services of a
surgeon or specialist, assistant, and anesthetist or
anesthesiologist together with preoperative and postoperative
care
6. Inpatient alcohol and substance abuse rehabilitation services in
a hospital, hospital residential treatment facility, or day
treatment program. Covered benefits for inpatient alcohol and
substance abuse rehabilitation services in a hospital, hospital
residential treatment facility, or day treatment program will be
provided under the same provisions as medical and surgical
benefits, with no additional financial or treatment
limitations.
7. Inpatient severe mental health services
Covered benefits for severe mental illness will be provided under
the same provisions as medical and surgical benefits, with no
additional financial or treatment limitations.
8. Outpatient hospital or outpatient surgical center services
9. Hospital services such as radiation therapy, chemotherapy
(including chemotherapy drugs) and outpatient surgery
10. Skilled nursing facility services (limited to 30 days per
calendar year) for non-custodial care
Prior care in a hospital is not required before being eligible for
care in a skilled nursing facility.
C. EMERGENCY SERVICES
Medically Necessary medical and/or Hospital services are covered in
the case of an Emergency.
If you have an Emergency:
Get help as soon as possible. Call your PCP or 911 for help or go
to the nearest emergency room,
Hospital, or other emergency facility. Call an ambulance if
necessary.
As soon as possible, make sure that we are told about your
emergency as set forth below. We need
to follow up on your emergency care.
Services must be provided at a Participating Provider unless the
time requirement to reach a Participating Provider would result in
a significant risk of permanent health damage. Unanticipated
complications of pregnancy or premature delivery are covered
outside our Service Area. Services furnished by a Physician, oral
surgeon, or Hospital or emergency facility personnel for Covered
Services are covered during the Emergency. Emergency medical and
Hospital services (inside or outside our Service Area) are limited
to situations that require immediate and unexpected treatment. You
should notify your PCP and our customer services department as soon
as possible following receiving Emergency services. If you are
outside our Service Area at the time of your Emergency, you should
notify your PCP and our customer services department as
City of Reno – Eligible Medical Expenses - 24 -
soon as possible upon your return to our Service Area to avoid a
denial of your claim. Notwithstanding anything in this EOC to the
contrary, for Non-Grandfathered Plans, coverage for Emergency
services will be provided:
Without the need for any prior-authorization determination whether
the health care Provider furnishing such Emergency services is a
Participating Provider with respect to such services;
Without regard to whether the Provider furnishing the Emergency
services is a Participating Provider with respect to the
services;
If the Emergency services are provided out of Network, without
imposing any administrative requirement or limitation on coverage
that is more restrictive than the requirements or limitations that
apply to Emergency services received from Participating
Providers;
If the Emergency services are provided out of Network, without the
cost-sharing requirement expressed as a Copayment amount or
Coinsurance rate imposed with respect to a participant or
beneficiary for the services exceeding the cost-sharing
requirements imposed if the services were provided in-Network;
and
without regard to any other terms or condition of such coverage
(other than exclusion or coordination of benefits, or an
affiliation or waiting period, as permitted by law, or applicable
cost-sharing).
Medical care and notification.
Medically Necessary Emergency medical care is available through
participating Physicians seven days a week, 24 hours a day.
Medically Necessary Emergency services out of our Service Area will
be covered. Out-of-area Emergency services are provided only if we
are notified before the receipt of those services or as soon as
possible after such Emergency services, but no more than 24 hours
after onset of the Emergency, except as provided in this
section.
Extended notification
If you are unable to contact us before you receive Emergency
medical services or within 24 hours of the Emergency due to shock,
unconsciousness, or otherwise, you must, at the earliest time
reasonably possible, contact our customer services department to
provide us with information about the event and relevant
circumstances.
Follow-up care (outside our Service Area/non-contracted
facility)
Continuing or follow-up treatment for an Emergency service outside
of our Service Area or from a non- Network facility is limited to
care required before you can, without harmful or injurious
consequences, return to our Service Area and receive care from
Participating Providers as determined by us. Benefits for
continuing or follow-up treatment(s) are otherwise covered only in
our Service Area from Participatin