Evidence of
Coverage
EFFECTIVE JANUARY 01, 2017
Children’sCommunityHealthPlan(CCHP)
POBox1997,MS6280
Milwaukee,WI53201
1-844-201-4672
TogetherwithChildren’sCommunityHealthPlan
UnderwrittenbyChildren’sCommunityHealthPlan
ExclusiveProviderOrganizationEvidenceofCoverage
ThisContractcontainsthetermsandconditionsofYourinsurancecoverage. WeissuedthisContractin
considerationoftheapplicationandpaymentofthefirstpremium.
IMPORTANTNOTICE:STATEMENTSMADEINYOURAPPLICATION
PleasewriteUswithin10daysifanyinformationsubmittedinyourapplicationisincorrector
incomplete.Omissionsormisstatementsintheapplicationcouldcauseanotherwisevalidclaimtobe
denied.Theinsurancecoveragewasissuedonthebasisthattheanswerstoallquestionsandother
informationshownontheapplicationwerecorrectandcomplete.
IMPORTANTNOTICE:SERVICESOBTAINEDFROMOUT-OF-NETWORKPROVIDERS
ThisContractisforanExclusiveProviderOrganization. ExceptasspecificallystatedinthisContract,services
receivedfromanOut-Of-NetworkProviderarenotcovered.Inaddition,certainservicesYouwishtoreceive
fromIn-NetworkProvidersrequirePriorAuthorization.IfYouwishtoreceivecoverageforthoseservicesYou
mustobtainPriorAuthorizationfromUs.
IfYoudoobtainservicesfromanOut-Of-NetworkProviderthatarecoveredunderthisContract,theMaximum
AllowedAmountisdeterminedbyUsbasedonthisContract’sfeeschedule,usualandcustomarycharge(whichis
determinedbycomparingchargesforsimilarservicesadjustedtothegeographicalareawheretheservicesare
performed),orothermethodasdefinedinthisContract.
IfYouincurnon-coveredexpenses,Youareresponsibleformakingthefullpaymenttothehealthcare
Practitioner.ThefactthatahealthcarePractitionerhasperformedorprescribedamedicallynecessaryprocedure,
treatment,orsupply,orthefactthatitmaybetheonlyavailabletreatmentforabodilyinjuryorIllness,doesnot
meanthattheprocedure,treatmentorsupplyiscoveredunderthisContract.
RIGHTTORETURN
YouhavetherighttoreturnthisContractwithin10daysofreceipt. Allpremiumspaidwillberefunded,less
claimspaid,andtheContractwillbeconsiderednullandvoidfromtheEffectiveDate.
GUARANTEEDRENEWABILITY
ThisContractremainsineffectandisguaranteedrenewableeachyearexceptunderconditionsidentifiedinthe
WhenCoverageBeginsandEndssection.YoumustbeeligibleforinsuranceandpayYourpremiumtoremain
insured.PleasereadYourContractcarefullyandbecomefamiliarwithitsterms,limitsandconditions.
IMPORTANTNOTICE:PEDIATRICDENTALDISCLOSURE
ThisContractdoesnotincludepediatricdentalservicesasrequiredunderthefederalPatientProtectionand
AffordableCareAct. Thiscoverageisavailableintheinsurancemarketandcanbepurchasedseparately. 01/2017QHPPlan
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10/19/2016
PleasecontactYourinsuranceagent(broker)ortheFederallyFacilitatedMarketplace(healthcare.gov)ifYouwish
topurchasedentalcoverage.
IMPORTANTNOTICE:CHANGESTOTHECONTRACT
IfthetermsandconditionsofthisContractchange,WewillattachlegaldocumentscalledRidersand/or
Amendments.WewillnotifyYouinwritingofanychangestothisContract. Noonecanmakeanychangesto
theContractunlessthosechangesareinwriting.
Wehavetherighttochange,interpret,modify,withdraw,addbenefitsortoterminatetheContractas
permittedbylaw,withoutYourapproval.OnitsEffectiveDate,thisContractreplacesandoverrulesany
ContractWemayhavepreviouslyissuedtoYou. ThispolicywilltakeeffectontheEffectiveDatespecifiedin
theWhenCoverageBeginssection.CoverageunderthisContractwillbeginat12:01a.m.andendat12:00
midnightintheCentralTimeZone.TheContractisissuedintheStateofWisconsinandisgovernedby
applicableStateandfederallaws.
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INTRODUCTION/WELCOME
WelcometoTogetherwithChildren’sCommunityHealthPlan(CCHP). WearepleasedtoprovideYou
withthisContract. ThisContractwillexplainYourbenefits,rightsandresponsibilitiesandother
importantinformationaboutYourhealthinsurancecoverage.
WeencourageYoutoreadthisContractcarefullyandstoreitinaplaceYoucanfinditquickly. Manyof
thesectionsofthisContractarerelatedtoothersectionsofthedocumentsoYoumaynothaveallthe
informationYouneedbyreadingjustonesection. PleasecallCustomerServiceifYouhaveany
questions.
DEFINEDTERMS
WehaveincludedaDefinitionssectiontohelpexplaincertainterms.Ifawordiscapitalizedand
italicizedinthedocument,itwillbeincludedintheDefinitionssection.WhenWeusethewordsWe,
Us,andOur,WearereferringtoChildren’sCommunityHealthPlanorCCHP. WhenWeusethewords
YouandYour,WearereferringtothosewhoareCoveredPersons.
YOURCIVILRIGHTS
Children’sCommunityHealthPlan(CCHP)doesnotdiscriminateonthebasisofrace,color,national
origin,sex,age,disability,orotherlegallyprotectedstatus,initsadministrationoftheplan,including
enrollmentandbenefitdeterminations.
Children’sCommunityHealthPlanprovidesappropriateauxiliaryaidsandservices,includingqualified
interpretersforindividualswithdisabilitiesandinformationinalternateformats,freeofchargeandina
timelymanner,whensuchaidsandservicesarenecessarytoensureanequalopportunitytoparticipate
toindividualswithdisabilities.
Anypersonwhobelievessomeonehasbeensubjectedtodiscriminationonthebasisofrace,color,
nationalorigin,sex,ageordisabilitymayfileagrievance.Thegrievancemustbefiledwith60daysofthe
personfilingthegrievancebecomesawareoftheallegeddiscriminatoryaction.Itisagainstthelawfor
Children’sCommunityHealthPlantoretaliateagainstanyonewhofilesagrievance,orparticipatesinthe
investigationofagrievance.MemberscanrequestChildren’sCommunityHealthPlan’sgrievance
procedurebycontactingtheSection1557Coordinator:
Director,CorporateCompliance
999N.92ndStreet,C760
WauwatosaWI53226
Telephone:(414)266-2215
Fax:(414)266-6409
[email protected]
Membersmustsubmittheircomplaintsinwritingwiththeirname,address,theproblemoractionalleged
tobediscriminatoryandtheremedyorreliefsought.
MemberscanalsofileacomplaintofdiscriminationelectronicallythroughtheOfficeforCivilRights
ComplaintPortal,whichisavailableat:https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,orbymailat:
U.S.DepartmentofHealthandHumanServices
200IndependenceAvenue
SWRoom509F
HHHBuilding
Washington,D.C.20201
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INTERPRETERSERVICES
IfYouorsomeoneYou’rehelpinghasquestionsaboutTogetherwithCCHP,Youhavetherighttogethelp
andinformationinyourlanguageatnocost.Totalktoaninterpreter,call1-844-201-4672.IfYouare
hearingimpaired,call1-844-531-4856.
SPANISH:Siusted,oalguienaquienustedestáayudando,tienepreguntasacercadeTogether with
CCHPtienederechoaobtenerayudaeinformaciónensuidiomasincostoalguno.Parahablarconun
intérprete,llameal1-844-201-4672.
HMONG:Yogkoj,losyogtejtusneeguaskojpabntawd,muajlusnugtxogTogether with CCHP,koj
muajcaikomlawvmuabcovntshiablusqhiauastaumuabsauuakojhomluspubdawbraukoj.Yogkoj
xavnrogibtugneegtxhaislustham,hurau1-844-201-4672.
CHINESE: 如果您，或是您正在協助的對象，有關於[插入SBM項目的名稱Together with
CCHP面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話
[在此插入數字1-844-201-4672.
GERMAN:FallsSieoderjemand,demSiehelfen,FragenzumTogether with CCHPhaben,habenSie
dasRecht,kostenloseHilfeundInformationeninIhrerSprachezuerhalten.UmmiteinemDolmetscher
zusprechen,rufenSiebittedieNummer1-844-201-4672an.
ARABIC: ‫ ) ﺑﺧﺻوص أﺳﺋﻠﺔ ﺗﺳﺎﻋده ﺷﺧص ﻟدى أو ﻟدﯾك ﻛﺎن إن‬Together with CCHP(، ‫ﻋﻠﻰ اﻟﺣﺻول ﻓﻲ اﻟﺣق ﻓﻠدﯾك‬
‫ﺗﻛﻠﻔﺔ اﯾﺔ دون ﻣن ﺑﻠﻐﺗك اﻟﺿرورﯾﺔ واﻟﻣﻌﻠوﻣﺎت اﻟﻣﺳﺎﻋدة‬. ‫ ) ب اﺗﺻل ﻣﺗرﺟم ﻣﻊ ﻟﻠﺗﺣدث‬1-844-201-4672.
FRENCH:Sivous,ouquelqu'unquevousêtesentraind’aider,adesquestionsàproposdeTogether
with CCHPvousavezledroitd'obtenirdel'aideetl'informationdansvotrelangueàaucuncoût.Pour
parleràuninterprète,appelez1-844-201-4672.
TAGALOG:Kungikaw,oangiyongtinutulangan,aymaymgakatanungantungkolsaTogether with
CCHP,maykarapatankanamakakuhangtulongatimpormasyonsaiyongwikangwalanggastos.Upang
makausapangisangtagasalin,tumawagsa1-844-201-4672.
ALBAINIAN:Nëseju,osedikushqëpondihmoni,kapyetjepërTogether with CCHP,kenitëdrejtëtë
merrnindihmëdheinformacionfalasnëgjuhëntuaj.Përtëfolurmenjëpërkthyes,telefononinumrin1844-201-4672.
HINDI: य$द आपके ,या आप +वारा सहायता ककए जा रहे ककसी 4य5तत के Together with CCHPके
बारे म8 9:न ह< ,तो आपके पास अपनी भाषा म8 मB
ु त म8 सहायता और सच
ू ना 9ाFत करने का अGधकार है ।
ककसी ि◌◌ुभाषषए से बात करने के Mलए 1-844-201-4672.पर कॉि◌ कर8 ।
POLISH:JeśliTylubosoba,którejpomagasz,maciepytaniaodnośnieTogether with CCHP,masz
prawodouzyskaniabezpłatnejinformacjiipomocywewłasnymjęzyku.Abyporozmawiaćztłumaczem,
zadzwońpodnumer1-844-201-4672.
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VIETNAMESE:Nếuquývị,hayngườimàquývịđanggiúpđỡ,cócâuhỏivềTogether with CCHP,quý
vịsẽcóquyềnđượcgiúpvàcóthêmthôngtinbằngngônngữcủamìnhmiễnphí.Đểnóichuyệnvớimột
thôngdịchviên,xingọi1-844-201-4672.
PENNSYLVANIA DUTCH:WannduhoschtenFroog,odderebber,wuduhelfscht,hotenFroogbaut
Together with CCHP,hoschtduesRechtferHilfunInformationindeinreeegneSchproochgriege,un
dieHilfkoschtetnix.WanndumitmeInterpreterschwetzewitt,kannschtdu1-844-201-4672uffrufe.
LAOTIAN: ້ ◌າທ
່ ານ,ຫ ຼ◌ື ◌ຄ
່ ານກ
ໍ າລ
່ ວຍເຫ ຼ◌ື ◌ອ,ມ ໍຄາຖາມກ
່ ຽວກ
ັ ງຊ
ັ ບ Together with CCHP,
ົ ນທ ່ ◌ທ
່ໍ ມ ຄ
ທ
ູ ນຂ
ັ ນພາສາຂອງທ
່ ານມ ິສດທ ່ ◌ຈະໄດ
້ ຮ
່ ວຍເຫ ຼ◌ື ◌ອແລະຂ
ໍ້ ມ
່ າວສານທ ່ ◌ເປ
່ ານບ
່ າໃຊ
້ ຈ
່ າຍ.
ັ ບການຊ
ການໂອ
້ ລ
້ ໂທຫາ 1-844-201-4672.
ັ ບນາຍພາສາ,ໃຫ
ົ ມກ
KOREAN: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이Together with CCHP에 관해서 질문이
있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가
있습니다.그렇게 통역사와 얘기하기 위해서는1-844-201-4672로 전화하십시오.
RUSSIAN:Еслиувасилилица,которомувыпомогаете,имеютсявопросыпоповодуTogether with
CCHP,товыимеетеправонабесплатноеполучениепомощииинформациинавашемязыке.Для
разговораспереводчикомпозвонитепотелефону1-844-201-4672.
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RIGHTSANDRESPONSIBILITIES
YOUHAVETHERIGHTTO:
• AskforaninterpreterandhaveoneprovidedtoYouduringanyCoveredService.
• Receivetheinformationprovidedinanotherlanguageoranotherformat.
• Receivehealthcareservicesasprovidedforbyfederalandstatelaw.AllCoveredServicesmust
beavailableandaccessibletoYou.Whenmedicallyappropriate,servicesmustbeavailable24
hoursaday,sevendaysaweek.
• Receiveinformationabouttreatmentoptionsincludingtherighttorequestasecondopinion
regardlessofthecostorbenefitcoverage.
• ParticipatewithPractitionersinmakingdecisionsaboutYourhealthcareregardlessofthecostor
benefitcoverage.
• Betreatedwithdignityandrespect.YouhavearighttoprivacyregardingYourhealth.
• Befreefromanyformofrestraintorseclusionusedasameansofforce,control,easeorreprisal.
• ReceiveinformationaboutUs,Ourservices,Practitionersandprovidersandmemberrightsand
responsibilities.
• VoicecomplaintsorappealswithUsorthecareWeprovide.
• MakerecommendationsregardingOurmemberrightsandresponsibilitiespolicy.
• AcandiddiscussionofappropriateorMedicallyNecessarytreatmentoptionsforYourcondition,
regardlessofcostorbenefitcoverage.
YOUHAVETHERESPONSIBILITYTO:
•
•
•
•
•
•
ReadthisContract
ReadandunderstandtothebestofYourabilityallmaterialsconcerningYourhealthbenefitsandask
forhelpifYouneedit.
Beenrolledandpayrequiredcontributions
BenefitsareavailabletoYouonlyifYouareenrolledforcoverageunderthisContract.Your
enrollmentoptions,andthecorrespondingdatesthatcoveragebeginsarelistedintheWhen
CoverageBeginsandEndssection.
BeAwarethisContractdoesnotpayforallhealthservices
YourrighttoBenefitsislimitedtoMedicallyNecessaryCoveredServices. Theextentofthis
Contract’spaymentsforthoseCoveredServicesandanyobligationthatYoumayhavetopayfora
portionofthecostoftheseCoveredServicesissetforthintheScheduleofBenefits.
ChooseYourPractitioner
ItisYourresponsibilitytoselectthehealthcareprofessionalswhowilldelivercaretoYou.We
arrangeforPractitionersandotherhealthcareprofessionalsandfacilitiestoparticipateina
Network.Ourcredentialingprocessconfirmspublicinformationabouttheprofessionals’and
facilities’licensesandothercredentials,butdoesnotassurethequalityoftheirservices.These
professionalsandfacilitiesareindependentPractitionersandentitiesthataresolelyresponsiblefor
thecaretheydeliver.
ParticipateinYourownHealthCare
DecisionsarebetweenYouandYourPractitioner. TalktoYourdoctoraboutwhatheorsheneedsto
knowtotreatYou. FollowthetreatmentplanagreeduponbyYouandYourdoctor.
PayYourShare
YoumustpayanannualDeductible,Copaymentand/orCoinsuranceformostCoveredServices.
ThesepaymentsaredueatthetimeofserviceorwhenbilledbythePractitioner.Deductible,
CopaymentandCoinsuranceamountsarelistedintheScheduleofBenefits.Youmayalsobe
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RightsandResponsibilities
RIGHTSANDRESPONSIBILITIES
•
•
requiredtopaythedifferencebetweentheactualchargeandtheMaximumAllowedAmountplus
anyDeductibleand/orCoinsurance/Copayments.
PaytheCostofExcludedServices
Youmustpaythecostofallexcludedservicesanditems. Reviewthe Exclusionssectiontobecome
familiarwithOurexclusions.
ShowYourIdentificationCard
YoushouldshowYouridentificationcard(ID)everytimeYourequesthealthservices.IfYoudonot
showYourIDcard,thePractitionermayfailtobillthecorrect fortheservicesdelivered,andany
resultingdelaymaymeanthatYouwillbeunabletoreceiveBenefits.
PREMIUMS,GRACEPERIODANDREINSTATEMENT
WedeterminethepremiumratesforthisContractandallsubsequentpremiumsforallCoveredPersons
underthisContract.WemaychangethepremiumratesunderthisContractwhenDependentsareadded
ordeletedorannuallyeffective[January1st]ofeachyear.Ifyouareatobaccouserage40orolder,your
premiumrateswillreflectthisstatus.
WewillprovidewrittennoticeofapremiumratechangetotheContractHolderbytheearliestof:(1)
thefirstdayoftheannualopenenrollmentperiod;or(2)atleast30daysbeforeanysuchchangetakes
effectforthisContract.However,whenthepremiumrateisincreased25%ormoreforapayment
period,WewillprovidewrittennoticeofthenewpremiumratetotheContractHolderatleast60days
beforeanychangetakeseffect.Thepremiumratechangetakeseffectonthefirstdayofthepayment
periodasdescribedintherequirednotice.
TheduedateofYourpremiumisindicatedonYourbillingstatement,whichwillarrivemonthly.Inorder
tokeepYourcoverageineffect,YoumustpayYourpremiumbytheendoftheapplicablegraceperiod
afterYourpremiumduedate.IfWedonotreceiveYourpremiumpayment,thisContractwillterminate
onthedayimmediatelyfollowingthelastdayoftheapplicablegraceperiod.
ExceptforYourfirstpremium,anypremiumnotpaidtoUsbytheduedateisindefault.However,there
isagraceperiodbeginningwiththefirstdayofthepaymentperiodduringwhichyoufailtopaythe
premium.Yourgraceperiodis30daysfromtheduedate,unlessyouarereceivinganadvancedpremium
taxcreditfromtheFederalGovernment,inwhichcaseyouwillhavea3-monthgraceperiod.Ifyouare
receivinganadvancedpremiumtaxcreditfromtheFederalGovernment,Wereservetherighttopend
paymentofallapplicableclaimsthatoccurinthesecondandthirdmonthofthegraceperiod.
YourContract willremaininforceduringthegraceperiod.Anyclaimsforcoveredservicesincurred
duringthegraceperiodwillbedeductedfromandappliedtothepremiumdueforthegraceperiod.If
fullpremiumpaymentisnotreceivedbytheendofthegraceperiod,YourcoverageunderthisContract
willterminate.
IfWeacceptpremiumpaymentfromtheContractHolderwithinoneyearaftertheContracthasbeen
canceledfornon-paymentofpremium;theContract willbereinstated.TheEffectiveDateofthe
reinstatedContract willbethedatefollowingthenon-paymentterminationdate.Thisiscalled
acceptancewithoutreservation.
IfWeacceptwithreservation,thismeansthatWedeliverormailyouawrittenstatementofreservation
within45daysafterWereceivedYourpremiumpayments.IfYourContractisreinstatedundertheterms
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RightsandResponsibilities
RIGHTSANDRESPONSIBILITIES
ofthisprovision,orifWereinstateYourContractwithinoneyearafterthedateoftermination
anyclaimsforservicesbetweenthedateofterminationandtheEffectiveDateorreinstatementofthis
Contract willnotbecovered.Nopremiumispayableforthatperiodexcepttotheextentthatthe
premiumisappliedtoareserveforfuturelosses.
Wehavetherighttochargeyouareinstatementfeeinaccordancewiththeschedulethathasbeenfiled
andapprovedbytheOfficeoftheCommissionerofInsuranceasnotexcessiveandnotunreasonably
discriminatory.Inallotherrespects,thisContractshallbetreatedasanuninterruptedContract.
NOTICEOFPRIVACYPRACTICES
ThisnoticedescribeshowprotectedhealthinformationaboutourCoveredPersonsmaybeusedand
disclosedandhowYoucangetaccesstothisprotectedhealthinformation.Pleasereviewthisnotice
carefully.
WearecommittedtoprotectingYourpersonalprivacy.ThisnoticeexplainsOurPrivacyPractices,legal
responsibilitiesandYourrightsconcerningYourpersonalhealthinformation.
WereservetherighttochangeOurprivacypracticesandthecontentsofthisNoticeofPrivacyPractices
asallowedbylaw.WhenWemakeasignificantchangeinOurprivacypractices,Wewillchangethis
noticeandsendthisnoticetoOurCoveredPersonsorpostitonOurwebsiteattogetherCCHP.org.
PRIVACYOBLIGATIONS
Wearerequiredbylawto:
• Ensurethatpersonalhealthinformationiskeptprivate.
• ProvidetoYouaNoticeofPrivacyPractices.
• FollowthetermsofthisNoticeofPrivacyPractices.WemayuseanddiscloseYourpersonalhealth
information:
o ToYou,someonewhoisinvolvedinYourpatientcare,ortoaclosefriendorfamilymember
aboutYourcondition,Youradmissiontoahealthcarefacilityordeath.
o TotheSecretaryoftheDepartmentofHealthandHumanServices.
o Topublichealthagenciesintheeventofaserioushealthorsafetythreat.
o Toauthoritiesregardingabuse,neglectordomesticviolence.
o Inresponsetoacourtorder,searchwarrantorsubpoena.
o Forlawenforcementpurposes.
o Forresearchpurposesiftheresearchstudymeetsallprivacylawrequirements.
o Forspecializedgovernmentfunctionssuchasthemilitary,nationalsecurityandintelligence
activities.
o Toacoronerormedicalexaminerorfuneraldirector.
o Fortheprocurement,bankingortransplantationoforgans,eyesortissue.
o Tocomplywithworker’scompensationorsimilarlaws.
o Tohealthoversightagenciesforaudits,investigations,inspectionsandlicensurenecessary
forthegovernmenttomonitorthehealthcaresystemandprograms.
o WehavetherighttouseanddiscloseYourpersonalhealthinformationtopayforhealthcare
servicesandoperateourbusiness:
§ Toadoctor,ahospitalorotherhealthcarePractitioner,whichasksforYour
protectedhealthinformationinorderforYoutoreceivehealthcare.
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RightsandResponsibilities
RIGHTSANDRESPONSIBILITIES
§
§
§
TopayclaimsforcoveredservicesprovidedtoYoubydoctors,hospitalsorother
healthcarePractitioners.
FortheoperationsofChildren’sCommunityHealthPlansuchasprocessingYour
enrollment,respondingtoYourinquiries,addressingYourrequestsforservices,
coordinatingYourcare,resolvingdisputesandactivitiesforconductingmedical
management,qualityassurance,auditingandevaluationofhealthcare
professionals.
TocontactYouwithinformationabouthealth-relatedbenefitsandservicesor
treatmentalternativesthatmaybeofinteresttoYou.
CertainservicesmaybeprovidedtoChildren’sCommunityHealthPlanbyotherorganizationsknownas
“businessassociates.”Forexample,athird-partyadministratormayprocessYourclaimsotheclaimcan
bepaid.Yourprotectedhealthinformationwillbeprovidedtothebusinessassociatesotheclaimcanbe
paid.AllbusinessassociateswillberequiredbyUstosignanagreementtosafeguardYourprotected
healthinformation.
AllotherusesordisclosuresofYourprotectedhealthinformationrequireYourwrittenauthorization
beforetheprotectedhealthinformationisusedordisclosed.YoumayrevokeYourpermissionatany
timebynotifyingUsinwriting.Anyprotectedhealthinformationpreviouslyusedordisclosedbasedon
PriorAuthorizationcannotberevokedorreversed.
YOURRIGHTS
ThefollowingareYourrightswithrespecttoYourprotectedhealthinformation:
•
Inspectandcopy.YouhavetherighttoinspectandcopyYourprotectedhealthinformation.To
performaninspectionorrequestacopy,YoumustsubmitarequestinwritingtothePlan
AdministratorattheaddresslistedattheendofthisNoticeofPrivacyPractices.Youmaybecharged
areasonablefeeforcopiesprovided.InlimitedcircumstancesYoumaybedeniedtheopportunityto
inspectandcopyYourprotectedhealthinformation.Generally,ifYouaredeniedaccesstoYour
protectedhealthinformation,Youmayrequestareviewofthedenial.
•
Requestamendment.Youhavetherighttorequestanopportunitytoamendanyprotectedhealth
informationthatYoufeelisincorrectorincomplete.TorequesttheopportunitytoamendYour
protectedhealthinformation,YoumustsendarequesttothePlanAdministratorattheaddress
listedattheendofthisNoticeofPrivacyPractices.ThisrequestmustcontainthereasonYoufeelthe
protectedhealthinformationisincorrectorincomplete.YourrequesttoamendYourprotected
healthinformationmaybedeniedsuchaswheretheprotectedhealthinformationis:
o Accurateandcomplete.
o NotcreatedbyUs.
o NotincludedintheprotectedhealthinformationkeptbyorforChildren’sCommunityHealth
Plan.
o NotprotectedhealthinformationYouhavetherighttoinspect.
•
Requestanaccountingofdisclosures.YouhavetherighttoobtainfromChildren’sCommunity
HealthPlanalistofdisclosuresthehealthplanhasmadetoothers,exceptthosedisclosures
necessaryforhealthcaretreatment,payment,healthcareoperationsordisclosuresmadetoyouor
othercertaintypesofdisclosures.Torequestanaccountingofdisclosures,YoumustsubmitYour
requestinwritingtotheplanadministratorattheaddresslistedattheendofthisNoticeofPrivacy
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RightsandResponsibilities
RIGHTSANDRESPONSIBILITIES
Practices.Yourrequestmuststateatimeperiod,whichmaynotbelongerthansixyearsbeforethe
dateoftherequest,andmaynotrequestanydisclosuresmadebeforeDec.1,2005.IfYourequesta
listofdisclosuresmorethanonceina12-monthperiod,WemaychargeYouareasonable,cost-
basedfeeforrespondingtotheserequests.
•
Requestrestrictions.Youhavetherighttorequestarestrictionontheprotectedhealthinformation
disclosedaboutYoufortreatment,paymentorhealthcareoperations.Children’sCommunityHealth
PlanisnotrequiredtoagreetoYourrequest.Torequestrestrictions,YoumustsubmitYourrequestin
writingtothePlanAdministratorattheaddresslistedattheendofthisNoticeofPrivacyPractices.You
mustincludeinYourrequest:
o TheinformationYouwishtorestrict.
o WhetherYouwishtolimittheuseordisclosureoftheprotectedhealthinformation,orboth.
o TowhomYouwanttherestrictiontoapply.
•
Requestconfidentialcommunications.YouhavetherighttorequestthatChildren’sCommunity
HealthPlancommunicateswithYouabouthealthmattersinacertainwayorinacertainlocation.To
requestconfidentialcommunications,YoumustsubmitYourrequestinwritingtothePlan
AdministratorattheaddresslistedattheendofthisNoticeofPrivacyPractices.Yourrequestmust
indicatehowand/orwhereYouwishtheconfidentialcommunicationtooccur.Wewillmakeevery
attempttoaccommodateallreasonablerequestsforconfidentialcommunications.
•
PapercopyoftheNoticeofPrivacyPractices.CoveredPersonsmayrequestacopyofthisnotice
atanytime.YoumaysubmitYourrequestforacopyofthisnoticeinwritingtothePlan
AdministratorattheaddresslistedattheendofthisNoticeofPrivacyPractices.
•
FileawrittenComplaint.IfYoubelieveYourprivacyrightsunderthisContracthavebeenviolated,
YoumayfileawrittencomplaintwithChildren’sCommunityHealthPlan’sprivacyofficeratthe
addresslistedbelow.Alternatively,YoumaycomplaintotheSecretaryoftheUnitedStates
DepartmentofHealthandHumanServices.Youwillnotbepenalizedorincurretaliationforfilinga
complaint.
•
Planadministrationandprivacyofficercontactinformation:
PlanAdministrator
PrivacyOfficer
VicePresidentDirectorofCorporateCompliance
Children’sCommunityHealthPlan Children’sCommunityHealthPlan
POBox1997POBox1997
Milwaukee,WI53201
Milwaukee,WI53201
[1-414-266-6328]
[1-414-266-2215]
CCHP17.EOC
10
RightsandResponsibilities
WHENCOVERAGEBEGINSANDENDS
ELIGIBILITYFORCOVERAGE
Youmayenrollforcoveragebycompletingandsigninganapplicationandpayinganyrequiredpremium
duringanenrollmentperiod,describedbelow. YourcoverageunderthisContractwillbeginonYour
EffectiveDateifWehavereceivedYourfirstmonth’spremiumWearenotresponsibleforclaims
incurredwhenYouorYourDependentsarenoteligibleforcoverage.IfWepayclaimsandlaterlearnYou
orYourDependent(s)werenoteligibleforcoverage,YouwillberesponsibletopayUsorthePractitioner
back.Youwillalsoberesponsibleforattorney’sfeesandexpensesthatWeincurinrecoveringOur
payments.
CONTRACTHOLDERELIGIBILITY
YouwillbecomeeligibleforthisContractifYou:
• Enrollforcoveragebycompletingandsigninganapplication;
• AreaWisconsinresidentandresideinOurServiceAreadefinedinthisContract;and
• Meettherequirementsforbeinga“qualifiedindividual”undertheHealthInsurance
Marketplace,including(butnotlimitedto)eachofthefollowing:
o YouareacitizenornationaloftheUnitedStatesoranon-citizenwhoislawfullypresent
intheUnitedStates.
o YoureasonablyexpecttobeacitizenornationaloftheUnitedStatesoranoncitizenwho
islawfullypresentintheUnitedStatesfortheentireperiodforwhichenrollmentis
sought.
o Youarenotincarcerated(otherthanincarcerationpendingdispositionofcharges).
DEPENDENTELIGIBILITY
YourDependent,iseligibleforcoverageunderthisContractifYoucompleteandsignanapplicationfor
coveragethatnamestheDependentasYourDependent;
EFFECTIVEDATEOFCOVERAGE
ANNUALOPENENROLLMENTPERIOD
AnnualopenenrollmentperiodisthetimeframewhenYoumayenrollYourselfandDependents,as
determinedbytheHealthInsuranceMarketplace.
Theannualopenenrollmentperiodstarts[November1andrunsthroughJanuary31.]IfYouselect
coverageduringtheannualopenenrollmentperiodonorbefore[December15]theEffectiveDateof
coveragewillbeJanuary1ofthefollowingyear.
IfYouselectcoverageduringtheannualopenenrollmentperiodafter[December15]theEffectiveDate
ofcoveragewillbeonthefirstdayofthemonthafterthesecondfollowingmonth.
SPECIALENROLLMENTPERIODS
YoumayenrollYourselforaDependentduringa60-dayspecialenrollmentperiod.Todoso,Youmust
completeandsignanapplicationforcoverageandpayanyrequiredpremiumduringtheperiod.Your
(orYourDependent’s)EffectiveDateofcoveragewillbeoneofthefollowing.
• Ifthespecialenrollmentperiodisforbirth,adoption,placementforadoption,orplacementin
fostercare,theEffectiveDateofcoveragewillbethedateofbirth,adoption,placementfor
adoption,orplacementinfostercare.
CCHP17.EOC
11
WhenCoverageBeginsandEnds
WHENCOVERAGEBEGINSANDENDS
Inthecaseofanewbornchild,includingthenewbornofaqualifiedDependent
child,Yournewlybornchildiscoveredfromthemomentofbirth.
o Ifyouarerequiredtopayadditionalpremiumtoprovidecoverageforthe
newlybornchild,thenyoumustnotifyUsandpaytherequiredpremium
with60daysinordertocontinuecoverageforthenewlybornchildbeyond
theinitial60-dayperiod.IfYoudonotnotifyUsandpaytheadditional
premiumforthenewbornchildwithin60daysofbirth,Youmaystillobtain
coverageforthechildonorbeforehis/herfirstbirthdaybycompletingan
applicationandpayinganypast-duepremium.
o Ifthereisnoadditionalpremiumforthenewborn,Werequestthatyou
notifyUsofthebirthofYournewbornchild.
Ifthespecialenrollmentperiodisformarriageorlossofminimumessentialcoverage,the
EffectiveDateofcoveragewillbethefirstdayofthemonthfollowingthedateofmarriageor
lossofminimumessentialcoverage.
Ifthespecialenrollmentperiodisforanyotherreason,theEffectiveDateofcoveragewillbeas
follows:
o
•
•
DateYouSelectYourPlan
EffectiveDate
1st–15thofthemonth
16th–lastdayofthemonth
Firstdayofthefollowingmonth*
Firstdayofthesecondfollowingmonth*
Forexample,ifYouselectcoverageonMarch9th,YourEffectiveDatewillbeApril1.
IfYouselectcoverageonMarch20th,YourEffectiveDatewillbeMay1.
*TheHealthInsuranceMarketplacemaydesignateanearlierEffectiveDateofcoverageincertain
circumstances.
AContractHoldermusthavecoverageineffectforaDependent’scoveragetobecomeeffective.
MembersoffederallyrecognizedtribesandAlaskaNativeClaimsSettlementAct(ANCSA)Corporation
shareholderscanenrollincoverageanytimeofyear.There’snolimitedenrollmentperiodforthese
individuals,andtheycanchangeplansuptoonceamonth.
TERMINATIONOFCOVERAGE
ThisContractshallterminateontheearliestofthefollowingdates:
• ThenextpremiumduedateafterWereceivetheCoveredPerson’swrittenrequesttoterminate
coverageunderthisContract;
• WithrespecttotheContractHolder’scoveredDependentspouseandanyDependent
stepchildrenwhoarechildrenoftheContractHolder’scoveredDependentspouse,thepremium
duedatecoincidingwiththedateonwhichtheContractHolderisdivorcedorlegallyseparated
fromsuchspouseorsuchmarriagewasannulled;
• WithrespecttotheContractHolder’sDependentchild,thepremiumduedatecoincidingwith
thedateonwhichaDependentchildceasestomeetthedefinitionofDependent;
• WithrespecttoaContractHolderreceivinganadvancedpremiumtaxcreditfromtheFederal
Government,10daysafterdeliveryofwrittennoticethatYourpremiumispastdueoronthe
lastdayofthefirstmonthofthethree-monthgraceperiodifthepremiumthendueisnotpaid
bytheendofthegraceperiod,whicheverislater;
CCHP17.EOC
12
WhenCoverageBeginsandEnds
WHENCOVERAGEBEGINSANDENDS
•
•
•
•
•
•
•
•
WithrespecttoaContractHolderthatisnotreceivinganadvancedpremiumtaxcreditfromthe
FederalGovernment,10daysafterdeliveryofwrittennoticethatYourpremiumispastdueor
theendofthegraceperioddescribedabove,whicheverislater.
ThedatetheCoveredPersonhasbeendeterminedbyUstohavecommittedanactoffraudor
madeanintentionalmisrepresentationofmaterialfactunderthetermsofthisContract;
ThedatetheContractHoldernolongerresidesorlivesintheServiceAreaorinanareainwhich
Weareauthorizedtodobusiness.Coveragewillbeterminatedonlyifcoverageterminated
uniformlywithoutregardtoanyhealthstatusrelatedfactorsofCoveredPerson’s;
Thefirstdatefollowing90daysadvancewrittennoticebyUstotheCoveredPersonwhen
WemaylawfullydiscontinueofferingpoliciesofthistypeintheStateofWisconsin;
Thefirstdatefollowing180daysadvancewrittennoticebyUstotheCoveredPersonwhenWe
maylawfullydiscontinueofferingallhealthinsurancecoverageintheindividualmarketinthe
stateofWisconsin;
ThedatethisContractceasestobeaQualifiedHealthPlanandisdecertifiedbytheHealth
InsuranceExchange;
ThedateWeterminateasaQualifiedHealthPlanIssuer;or
WithrespecttoaCoveredPerson,thedateimmediatelyfollowingtheCoveredPerson’sdeath.
TheattainmentofthelimitingagebyacoveredDependentwillnotcausecoveragetoterminatewhile
thatpersonisandcontinuestobebothincapableofself-sustainingemploymentbyreasonofmentalor
physicalincapacityandchieflydependentonYouforsupportandmaintenance.
CCHP17.EOC
13
WhenCoverageBeginsandEnds
HOWTOOBTAINCOVEREDSERVICES
MEMBERIDENTIFICATIONCARD
WhenYouareenrolledincoverage,YouwillreceiveaMemberIdentificationCardinthemail. Youare
requiredtoshowYourIDcardbeforeYoureceiveservicesorcare.OnlyaCoveredPersonwhohaspaid
thePremiumsunderthisContracthastherighttoservicesorBenefitsunderthisContract.Ifanyone
receivesservicesorBenefitstowhichtheyarenotentitledtounderthetermsofthisContract,he/sheis
responsiblefortheactualcostoftheservicesorBenefits.IfYouloseYourcard,Youshouldordera
replacementcardthroughCustomerServicesbycalling[1-844-201-4672]orbyrequestingoneonline
through[CCHPConnect].
ACCESSINGCARE
TogetherwithChildren’sCommunityHealthPlanisanExclusiveProviderOrganizationplan,whichmeans
YoumustobtainservicesfromIn-NetworkProviders.In-NetworkProvidersarethekeytoprovidingand
coordinatingYourhealthcareservices. ServicesYouobtainfromanyPractitionerotherthananInNetworkProviderareconsideredOut-of-Network,unlessotherwiseindicatedinthisContract,andwill
notbecovered.YourProviderDirectoryincludesalistoftheIn-NetworkProvidersavailableintheService
Area.TheProviderDirectorycanbefoundonCCHP’swebsiteoraprintedversioncanbemailedtoYou
uponrequestfromCustomerService.
ItisimportanttocallYourPrimaryCareProviderfirstwhenYouneedcare.IfYouthinkYouneedtosee
anotherPractitionerorspecialist,YoucanaskYourPrimaryCareProviderwhowillhelpYoudecide,but
itisnotrequired.Areferralisnotrequiredtoseeaspecialistortogetasecondopinion.IfYoudonot
haveaPrimaryCareProvider,YoucanchooseonefromthoseavailableintheProviderDirectory.
IfYouarefemale,thenYoumayselectaPrimaryCareProviderwhospecializesinobstetricsor
gynecology. Youneverneedpriorauthorizationorareferralforobstetricalorgynecologicalcarebyan
In-NetworkProviderwhospecializesinobstetricsorgynecology.
OBTAININGCOVERAGEANDFILINGCLAIMS
IN-NETWORKPROVIDERS
ForservicesrenderedbyIn-NetworkProviders:
• YouwillnotberequiredtofileanyclaimsforservicesYouobtaindirectlyfromIn-Network
Providers. In-NetworkProviderswillseekpaymentforCoveredServicesfromUsandnotfrom
YouexceptforapplicableCoinsurance,Copayments,and/orDeductibles.Youmaybebilledby
YourPractitioner(s)foranynon-CoveredServicesYoureceiveorwhenYouhavenotactedin
accordancewiththisContract.
• WedonotdecidewhatcareYouneedorwillreceive.YouandYourPractitionermakethose
decisions.
OUT-OF-NETWORKPROVIDERSOROUTSIDETHESERVICEAREA
There is NO coverage available outside of the Service Area, unless it is an Emergency or if Prior
Authorizationhasbeenobtained.IfYouareoutsideoftheServiceArea,orifYouareintheServiceArea,
but seek coverage by an Out-of-Network Provider, and it is not an Emergency, and Prior Authorization
hasnotbeenobtained,Youareresponsibleforallrelatedfeesandexpenses.
WhenYoureceiveCoveredServicesfromanOut-of-NetworkProvider,theclaimmustbefiledinaformat
that contains all of the information We require, as described below.The Practitionerwill likely file
theclaimforpaymentfromUs,butultimatelyYouareresponsible.
CCHP17.EOC
14
HowtoObtainCoveredServices
HOWTOOBTAINCOVEREDSERVICES
FILINGACLAIM
YoushouldsubmitaclaimforpaymentofCoveredServiceswithin90daysafterthedateofservice. If
Youdon’tprovidethisinformationtoUswithin15monthsofthedateofservice,Benefitsforthathealth
service will be denied or reduced, at Our discretion. The time limit does not apply if You are legally
incapacitated. If Your claim relates to an Inpatient stay, the date of service is the date Your Inpatient
stayends.
Requiredinformation:arequestforthepaymentofBenefitsshouldincludethefollowinginformation:
•
•
•
•
•
•
•
•
TheContractHolder’snameandaddress
Thepatient’snameandage
ThenumberonYourIDcard
ThenameandaddressofthePractitioneroftheCoveredServices
Thenameandaddressofanyorderingphysician
Adiagnosisfromthephysician
An itemized bill from Your Practitionerthat includes the Current Procedural Terminology
(CPT)codesoradescriptionofeachcharge
ThedatetheInjuryorSicknessbegan
YoushouldfiletheclaimattheaddressonYourIDcard.
RELATIONSHIPBETWEENCCHPANDNETWORKPROVIDERS
TherelationshipbetweenUsandourIn-NetworkProvidersisanindependentcontractorrelationship.In-
NetworkProvidersarenotagentsoremployeesofOurs,norisCCHP,oranyemployeeofOurs,an
employeeoragentofanIn-NetworkProvider.
YourhealthcarePractitionerissolelyresponsibleforalldecisionsregardingYourcareandtreatment,
regardlessofwhethersuchcareandtreatmentisaCoveredService.Weshallnotberesponsibleforany
claimordemandonaccountofdamagesarisingoutof,orinanymannerconnectedwith,anyInjuries
sufferedbyaCoveredPersonwhilereceivingcarefromanyIn-NetworkProviderorinanyIn-Network
Provider’sfacilities.
YourIn-NetworkProvider’sagreementforprovidingCoveredServicesmayincludefinancialincentivesor
risksharingrelationshipsrelatedtotheprovisionofservicesorreferralstootherPractitioners,including
In-Network Providers, Out-of-Network Providers, and disease management programs. If You have
questionsregardingsuchincentivesorrisksharingrelationships,pleasecontactYourPractitionerorUs.
NOTLIABLEFORPROVIDERACTSOROMISSIONS
WearenotresponsiblefortheactualcareYoureceivefromanyperson.ThisContractdoesnotgive
anyoneanyclaim,rightorcauseofactionagainstUsbasedontheactionsofaPractitionerofhealth
care,services,orsupplies.
CONTINUITYOFCARE
IfYourPrimaryCareProvider’sparticipationinthenetworkterminates,Youhavetherighttocontinueto
accessthatPractitionerattheIn-NetworkBenefitleveluntiltheendofthecurrentContractyear.
CCHP17.EOC
15
HowtoObtainCoveredServices
HOWTOOBTAINCOVEREDSERVICES
IfYouareundergoingacourseoftreatmentwithaPractitionerwhoisnotaPrimaryCareProvider,and
thatPractitioner’sparticipationinthenetworkterminates,Youhavetherighttocontinuetoaccessthat
PractitionerattheIn-NetworkBenefitslevelforupto90daysortheendofYourcourseof
treatment,whicheverisshorter.
IfYouareinYour2ndor3rdtrimesterofpregnancyandYourPractitioner’sparticipationinthe
networkterminates,YouhavetherighttocontinuetoaccessthatPractitionerforYourmaternity
careattheIn-NetworkBenefitsleveluntilthecompletionofpostpartumcare.
IfYouwishtoexerciseyourContinuityofCarerightsandcontinueseeingYourPractitionerforthetime
periodspecifiedabove,pleasecontactourCustomerServicestaff,sothatwecanensureYourclaimsare
paidappropriately.OurCustomerServicestaffcanalsohelpYouinselectinganotherIn-Network
ProviderforYourcare.
PleasenotethattheprovisionsoutlinedinthissectionarenotapplicableforPractitionerswhoare
nolongerpracticingintheServiceAreaorwhowereterminatedfromthisplanforfailuretomeet
credentialingstandards.
CCHP17.EOC
16
HowtoObtainCoveredServices
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
InthisContract,italicizedwordsaredefined.Wordsnotitalicizedwillbegiventheirordinarymeaning.
ACUTEMEDICALREHABILITATIONFACILITY
AfacilitythatprovidesacutecareforRehabilitativeServicesforaSicknessoranInjuryonanInpatient
basis.AdistinctsectionofaHospitalsolelydevotedtoprovidingacutecareforRehabilitativeServices
wouldalsoqualifyasanAcuteMedicalRehabilitativeFacility.Thesetypesoffacilitiesmustmeetallof
thefollowingrequirements:
• BelicensedbythestateinwhichtheservicesarerenderedandaccreditedbytheJoint
CommissiononAccreditationofHealthcareOrganizations(JCAHO)orCommissionon
AccreditationofRehabilitationFacilities(CARF)toprovideacutecareforRehabilitativeServices.
• Bestaffedbyanondutyphysician24hoursperday.
• Providenursingservicessupervisedbyanondutyregisterednurse24hoursperday.
• Provideaninitial,clearlydocumentedcareplanuponadmissionandongoingcareplansfor
patientsonaregularbasisthatincludereasonable,appropriateandattainableshortand
intermediatetermgoals.
• Provideatotalofatleast3hoursperdayofanycombinationofactivePhysicalTherapy,
OccupationalTherapyandSpeechTherapybyanappropriatelylicensedhealthcarePractitioner
toeachpatientatleast6daysperweek.ACoveredPersonmustbeableandwillingto
participateactivelyintheseservicesforatleasttheabovereferencedtimeframes.Cognitive
therapy,counselingservices,passiverangeofmotiontherapy,respiratorytherapyandsimilar
servicesmaybeprovidedbutarenotincludedinthe3hourminimumperdayrequirementof
activePhysicalTherapy,OccupationalTherapyandSpeechTherapy.
• NotprimarilyprovidecareforMentalHealthorSubstanceAbuseDisordersalthoughthese
servicesmaybeprovidedinadistinctsectionofthesamephysicalfacility.
ADMINISTRATOR
AnorganizationorentitydesignatedbyUstomanagethebenefitsprovidedinthisplan.Thedesignated
AdministratorwillhavethediscretionaryauthoritytoactonOurbehalfintheadministrationofthis
plan.TheAdministratormayenterintoagreementswithvariousPractitionerstoprovideservices
coveredunderthisplan.
ADVERSEBENEFITDETERMINATION
Adenial,reduction,terminationof,orfailuretoprovideormakepayment,inwholeorinpart,fora
Benefit,includinganysuchdenial,reduction,termination,orfailuretoprovideormakepaymentthatis
basedonadeterminationofaCoveredPerson’seligibilitytoparticipateinaplan.AdverseBenefit
Determinationalsoincludesarescissionofcoverage.
ALTERNATEFACILITY
AhealthcarefacilitythatisnotaHospitalandthatprovidesoneormoreofthefollowingserviceonan
Outpatientbasis,aspermittedbylaw:surgicalservices,emergencyhealthservices,rehabilitative,
laboratory,diagnosticortherapeuticservices,mentalhealthandsubstanceusedisorderservices.
APPEAL
AformalwrittenrequesttoreconsiderapreviousdecisionmadebyUs.
AUTHORIZEDREPRESENTATIVE
CCHP17.EOC
17
Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
AnindividualwhorepresentsYouinaninternalappealorexternalreviewprocessofanAdverseBenefit
Determinationwhoisanyofthefollowing:
• Apersontowhomacoveredindividualhasgivenexpress,writtenconsenttorepresentthat
individualinaninternalappealsprocessorexternalreviewprocessofanAdverseBenefit
Determination;
• ApersonauthorizedbylawtoprovidesubstitutedconsentforaCoveredPerson;
• AfamilymemberbutonlywhenYouareunabletoprovideconsent.
AUTISMINTENSIVELEVELSERVICES
Evidence-basedbehavioraltherapiesthataredesignedtohelpanindividualwithAutismSpectrum
Disorderovercomethecognitive,socialandbehavioraldeficitsassociatedwiththatdisorder.Intensive
LevelServicesmayincludeevidence-basedspeechtherapyandoccupationaltherapyprovidedbya
qualifiedtherapistwhensuchtherapyisbasedon,orrelatedto,anindividual'stherapeuticgoalsand
skills,andisconcomitantwithevidence-basedbehavioraltherapy.
AUTISMNON-INTENSIVELEVELSERVICES
Evidence-basedtherapythatoccursafterthecompletionoftreatmentforIntensivelevelservicesand
thatisdesignedtosustainandmaximizegainsmadeduringtreatmentwithIntensive-LevelServicesor,
foranindividualwhohasnotandwillnotreceiveIntensive-LevelServices,evidence-basedtherapythat
willimprovetheindividual'scondition.
AUTISMSPECTRUMDISORDER
Includesanyofthefollowing:
• Autismdisorder.
• AspergerSyndrome.
• PervasiveDevelopmentDisordernototherwisespecified.
BENEFITS
ThemaximumamountthatwillbeallowedforaCoveredService.Benefitsmaybeexpressedinmany
ways,suchasadollaramount,numberofdays,orthenumberofservices.SomeBenefitsarediscussed
inthisContract,butgenerallyaredescribedinYourScheduleofBenefits.
CARDIACREHABILITATION
Aprogramforpatientswithheartdiseaseaimedatensuringpatientspreserveorresumebestpossible
healthandfunctionalcapacity.Usuallyincludesanexercisetrainingcomponent.
CHIROPRACTICCARE
Neuromusculartreatmentintheformofmanipulationandadjustmentofthetissuesofthebody,
particularlyofthespinalcolumnandmayincludephysicalmedicinemodalitiesoruseofDurable
MedicalEquipment.
CLINICALTRIAL
Anyphaseofaclinicaltrialthatisconductedinrelationtotheprevention,detection,ortreatmentof
cancerorotherlife-threateningdiseaseorconditionandisdescribedinanyofthefollowing:
• Thestudyorinvestigationisapprovedorfunded(includingfundingthroughin-kind
contributions)byoneormoreofthefollowing:
CCHP17.EOC
18
Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
TheNationalInstitutesofHealth.
TheCentersforDiseaseControlandPrevention.
TheAgencyforHealthCareResearchandQuality.
TheCentersforMedicare&MedicaidServices.
CooperativegrouporcenterofanyoftheabovefourentitiesortheDepartmentof
DefenseortheDepartmentofVeteransAffairs.
o Aqualifiednon-governmentalresearchentityidentifiedintheguidelinesissuedbythe
NationalInstitutesofHealthforcentersupportgrants.
o TheDepartmentofVeteransAffairs,theDepartmentofDefense,ortheDepartmentof
Energy,butonlyifthestudyorinvestigationhasbeenreviewedandapprovedthrougha
systemofpeerreviewthattheSecretaryoftheDepartmentofHealthandHuman
Servicesdeterminestobecomparabletothesystemofpeerreviewofstudiesand
investigationsusedbytheNationalInstitutesofHealth,andassuresunbiasedreviewof
thehighestscientificstandardsbyqualifiedindividualswhohavenointerestinthe
outcomeofthereview.
Thestudyorinvestigationisconductedunderaninvestigationalnewdrugapplicationbythe
FoodandDrugAdministration.
Thestudyorinvestigationisadrugtrialthatisexemptfromhavingsuchaninvestigationalnew
drugapplication.
o
o
o
o
o
•
•
COINSURANCE
ThepercentageofexpensesforCoveredServicesthatyouareresponsibletopayaftermeetingYour
deductible,ifyouhaveone.TheamountofYourCoinsurancedependsontheplanyouselect.Referto
YourScheduleofBenefitstodetermineCoinsuranceamounts.
COMPLAINT
ACoveredPerson’soralexpressionofdissatisfaction.Complaintscaninvolvemanydifferentissues,
includingbutnotlimitedtothefollowing:
• Access–AppointmentAvailability
• Attitude
• Billing&Financial
• QualityofPractitionerOfficeSite:Physicalappearance,physicalaccessibilityofofficepractice
sites
• Concernsrelatedtoequityofcareordiscrimination
• Unprofessionaltreatmentbyprofessionals
• Medicalrecordaccessanddocumentation
• Patientcareclinicaloutcomes
• Patientsafety,harm, riskorpotentialsafetyconcerns
• FraudWasteorAbuse
• Privacy/HIPAAviolations
CONGENITALANOMOLY
Aphysicalorfunctionaldefectthatispresentatthetimeofbirthoridentifiedduringpregnancy,and
thatisidentifiedwithinthefirsttwelvemonthsoflife.
CONTRACT
CCHP17.EOC
19
Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
ThisdocumentissuedtotheContractHolderconsistingofthisEvidenceofCoverage,theScheduleof
Benefits,theenrollmentform,andanyamendments,riders,orendorsements.ThisContractindicates
thetermsandconditionsofYourinsurancecoverage.
CONTRACTHOLDER
ThepersontowhomtheContractisissued.
COPAYMENT
Thespecifieddollaramountthatyoupayatthetimeofserviceforcertaincoveredservices.Copayment
amountsdonotapplytowardYourCoinsuranceorDeductibleamount,butdoapplytoYourMaximum
Out-Of-Pocket.YouareexpectedtopayCopaymentsatthetimeofservice.RefertoYourScheduleof
BenefitstodetermineCopaymentamounts.
COSMETICSERVICES
Asurgery,procedure,injection,medication,ortreatmentprimarilydesignedtoimproveappearance,
self-esteemorbodyimageand/ortorelieveorpreventsocial,emotionalorpsychologicaldistress.
COVEREDDEPENDENT
ApersonwhomeetsthedefinitionofaDependentandisenrolledandeligibletoreceiveBenefitsunder
thisplan.
COVEREDPERSON
ApersonwhoiseligibletoreceiveBenefitsunderthisContract.
COVEREDSERVICE
Services,suppliesortreatmentasdescribedinthisContractwhichareperformed,prescribed,directed
orauthorizedbyaPractitioner.TobeaCoveredServicetheservice,supplyortreatmentmustbe
• ProvidedorincurredwhiletheCoveredPerson’scoverageisinforceunderthisContract;
• CoveredbyaspecificBenefitprovisionofthisContract;and
• NotexcludedanywhereinthisContract.
DEDUCTIBLE
TheamountofCoveredService,shownintheScheduleofBenefits,thatmustactuallybepaidbythe
CoveredPersonduringanycalendaryearbeforeanyBenefitsarepayable.ThefamilyDeductibleistwo
timestheindividualDeductibleamount.Forfamilycoverage,thefamilyDeductiblecanbemetwiththe
combinationofanyoneormoreCoveredPersons’eligibleserviceexpenses.If the family Deductible is
more than 2017 individual Maximum Out of Pocket Limit, the Deductible cannot be met by one
Covered Person. •
TheDeductibledoesnotincludeanyCopayments.
DEPENDENT
TheContractHolder’slegalspouse,child,grandchildorthechildorgrandchildoftheContractHolder’s
spouse.
Thetermchildincludesanyofthefollowing:
• Anaturalchild;
• AstepchildorachildforwhomlegalguardianshiphasbeenawardedtotheContractHolderor
ContractHolder’sspouse;
CCHP17.EOC
20
Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
•
•
•
Alegallyadoptedchild;
AchildplacedforadoptionwiththeContractHolder;
AchildforwhomhealthcarecoverageisrequiredthroughaQualifiedMedicalChildSupport
Orderorothercourtoradministrativeorder;
ThetermgrandchildmeansachildofacoveredDependentchilduntilthecoveredDependentwhoisthe
parentturns18yearsofage.
Achildlistedabovemustbeunder26yearsofageatthetimeofenrollment.
AchildwhomeetstherequirementssetforthaboveceasestobeeligibleasaDependentonthelastday
ofthemonthinwhichthechildturns26yearsofage,exceptforachildwhoisandcontinuestobeboth
incapableofself-sustainingemploymentbyreasonofmentalorphysicalincapacityandchiefly
dependentontheContractHolderforsupportandmaintenance.
ADependentwillalsoincludeanunmarriedchildage26orolderwhomeetsthefollowingcriteria:
• Thechildisunabletoholdaself-sustainingjobduetointellectualdisabilityorphysicalhandicap;
• ThechildischieflyDependentonYouforsupportandmaintenance;
• Thechild’sincapacityexistedbeforeheorshereachedage26;and
• YourfamilycoverageremainsinforceunderthisContract.
ADependentalsoincludesanadultchildwhomeetsallofthefollowing:
• Thechildisafull-timestudent,regardlessofage,attendinganaccreditedvocational,technical
oradulteducationschool,oranaccreditedcollegeoruniversity;or
• Thechildwasunderage27andcalledtofederalactivedutyintheNationalGuardorina
reservecomponentoftheU.S.ArmedForceswhileattending,onafull-timebasis,aninstitution
ofhighereducation.
TobeeligibleforcoverageundertheContract,aDependentmustresidewithintheUnitedStates.
TheCoveredPersonmustreimburseUsforanyBenefitsthatWepayforachildatatimewhenthechild
didnotsatisfytheseconditions.
DESIGNATEDTRANSPLANTPROVIDER
AhealthcarePractitioner,facilityorsupplier,asdeterminedbyUs,thataCoveredPersonmustuseto
obtainthemaximumBenefitsavailableunderthetransplantprovisionintheCoveredServicessection.
DIAGNOSTICIMAGING
X-rays,ultrasoundsorlikeproceduresthataregenerallyperformedtoaidinthediagnosisormonitoring
ofYourcondition.
DIAGNOSTICTESTING
Laboratorytestingofblood,tissueorotherspecimensthatisgenerallyperformedtoaidindiagnosisor
monitoringofYourcondition.
DURABLEMEDICALEQUIPMENT
CCHP17.EOC
21
Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
Equipmentthatmeetsallofthefollowingcriteria:
• IsusedtoserveamedicalpurposewithrespecttotreatmentofaSickness,bodilyInjuryortheir
symptomsratherthanbeingprimarilyforcomfortorconvenience.
• Canwithstandrepeateduse;
• Isnotdisposable;
• IsgenerallynotusefulintheabsenceofaSickness,bodilyInjuryortheirsymptoms;
• IsappropriatefortreatmentofYourbodilyInjuryorIllness;
• Isappropriateforuse,andisprimarilyused,withinthehome;
• Isnotimplantablewithinthebody;and
• IsprovidedinthemostcosteffectivemannerrequiredbyYourcondition,including,atOur
discretion,rentalorpurchase.
EFFECTIVEDATE
TheapplicabledatecoverageunderthisplanbeginsforaCoveredPerson.
ELIGIBLEPERSON
ApersonwhomeetstheeligibilityrequirementsspecifiedinboththeapplicationandthisContract.
EMERGENCY
Aconditionofsuddenonsetforamedicalconditionthatmanifestsitselfbyacutesymptomsofsufficient
severityorseverepainsuchthataprudentlaypersonwhopossessesanaverageknowledgeofhealth
andmedicinecouldreasonablyexpecttheabsenceofimmediatemedicalattentiontoresultinoneor
moreofthefollowing:
• Placingthehealthoftheindividual(orwithrespecttoapregnantwomanthehealthofthe
womanorherunbornchild)inseriousjeopardy
• Seriousimpairmenttobodilyfunctions
• Seriousdysfunctionofanybodilyorganorpart
• Otherseriousmedicalconsequences
EMERGENCYSERVICES
HealthcareservicesnecessaryforthetreatmentofanEmergency.
EmergencytransportationandrelatedEmergencyServicesprovidedbyalicensedambulanceservice
constituteanEmergencyServiceandwillbecoveredwhethertheserviceisprovidedbyanIn-Network
ProvideroranOut-of-NetworkProvider.Non-emergencyservicesprovidedbyanOut-of-Network
ProviderwillnotbecoveredunlessPriorAuthorizationfortheservicesisobtained.
EmergencyServicesdonotincludeservicesthatYouorYourcoveredDependentobtainsforhis/her
convenienceorpreference.
EXPERIMENTALORINVESTIGATIONALTREATMENT
Treatment,services,suppliesorequipmentwhich,atthetimethechargesareincurred,Wedetermine
are:
• NotproventobeofBenefitfordiagnosisortreatmentofaSicknessoranInjury;or
• Notgenerallyusedorrecognizedbythemedicalcommunityassafe,effectiveandappropriate
fordiagnosisortreatmentofaSicknessoranInjury;or
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Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
•
•
•
Intheresearchorinvestigationalstage,providedorperformedinaspecialsettingforresearch
purposesorunderacontrolledenvironmentorclinicalprotocol;or
ObsoleteorineffectiveforthetreatmentofaSicknessoranInjury;or
Medicationsusedfornon-FDAapprovedindicationsand/ordosageregimens.
Foranydevice,drug,orbiologicalproduct,finalapprovalmusthavebeenreceivedtomarketitbythe
FoodandDrugAdministration(FDA)fortheparticularSicknessorInjury.However,finalapprovalbythe
FDAisnotsufficienttoprovethattreatment,servicesorsuppliesareofprovenbenefitorappropriateor
effectivefordiagnosisortreatmentofaSicknessoranInjury.Anyapprovalgrantedasaninterimstepin
theFDAregulatoryprocess,suchasaninvestigationaldeviceexemptionoraninvestigationalnewdrug
exemptionisnotsufficient.
OnlyWecanmakethedeterminationastowhetherchargesareforExperimentalorInvestigational
Treatmentbasedonthefollowingcriteria:
• OncefinalFDAapprovalhasbeengranted,theusageofadevicefortheparticularSicknessor
Injuryforwhichthedevicewasapprovedwillberecognizedasappropriateif:
o Itissupportedbyconclusiveevidencethatexistsinclinicalstudiesthatarepublishedin
generallyacceptedpeer-reviewedmedicalliteratureorreviewarticles;and
o TheFDAhasnotdeterminedthemedicaldevicetobecontraindicatedfortheparticular
SicknessorInjuryforwhichthedevicehasbeenprescribed.
• OncefinalFDAapprovalhasbeengranted,theusageofadrugorbiologicalproductwillbe
recognizedasappropriateforaparticularSicknessorInjuryiftheFDAhasnotdeterminedthe
drugorbiologicalproducttobecontraindicatedfortheparticularSicknessorInjuryforwhich
thedrugorbiologicalproducthasbeenprescribedandtheprescribedusageisrecognizedas
Appropriatemedicaltreatmentby:
o TheAmericanMedicalAssociationDrugEvaluations;or
o TheAmericanHospitalFormularyServiceDrugInformation;or
o Conclusiveevidenceinclinicalstudiesthatarepublishedingenerallyacceptedpeer-
reviewedmedicalliteratureorreviewarticles.
• Foranyothertreatment,servicesorsupplies,conclusiveevidencefromgenerallyaccepted
peer-reviewedliteraturemustexistthat:
o Thetreatment,servicesorsupplieshaveadefinitepositiveeffectonhealthoutcomes.
Suchevidencemustincludewell-designedinvestigationsthathavebeenreproducedby
non-affiliatedauthoritativesources,withmeasurableresults,backedupbythepositive
endorsementsofnationalmedicalbodiesorpanelsregardingscientificefficacyand
rationale;and
o Overtime,thetreatment,servicesorsuppliesleadtoimprovementinhealthoutcomes
whichshowthatthebeneficialeffectsoutweighanyharmfuleffects;and
o Thetreatment,servicesorsuppliesareatleastaseffectiveinimprovinghealth
outcomesasestablishedtechnology,orareuseableinappropriateclinicalcontextsin
whichestablishedtechnologyisnotemployable.
EYEWEARBENEFITMANAGER
UsoranentitydesignatedbyUstomaintainthePediatricEyewearCollection.Thecollectionlistis
subjecttochangeatanytimewithoutnotice.TheEyewearBenefitManagermayalsodistributechild
CCHP17.EOC
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Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
eyewear,includingglasses(framesandlenses)orcontactlenses.CallUstoverifythenameofthe
EyewearBenefitManager.
FREE–STANDINGFACILITY
Afacilitythatprovidesinterventionalservices,onanOutpatientbasis,whichrequirehands-oncarebya
Practitionerandincludestheadministrationofgeneralorregionalanesthesiaorconscioussedationto
patients.Thistypeoffacilitymayalsobereferredtoasanambulatorysurgicalcenter,aninterventional
diagnostictestingfacility,afacilitythatexclusivelyperformsendoscopicproceduresoradialysisunit.A
designatedareawithinaPractitioner’sofficeorclinicthatisusedexclusivelytoprovideinterventional
servicesandadministeranesthesiaorconscioussedationisalsoconsideredtobeaFree-Standing
Facility.Roomandboardandovernightservicesarenotcovered.Thesefacilitiesmustmeetallofthe
followingrequirements:
• Belicensedbythestateinaccordancewiththelawsforthespecificservicesbeingprovidedin
thatfacility.
• NotprimarilyprovidecareforMentalHealthDisorderorSubstanceAbuseDisordersorbean
UrgentCareFacility.
GENETICCOUNSELING
Theprocessbywhichthepatientorrelativesatriskofaninheriteddisorderareadvisedoftheaccuracy
oftheproposedtesting,consequencesandnatureofthedisorder,theprobabilityofdevelopingor
transmittingit,andtheoptionsopentotheminmanagementandfamilyplanning.
GENETICTESTING
ExaminationofbloodorothertissueforchromosomalandDNAabnormalitiesandalterations,orother
expressionsofgeneabnormalitiesthatmayindicateanincreasedriskfordevelopingaspecificdisease
ordisorder.
HABILITATIVESERVICES
Healthcareservicesthathelpapersonacquire,maintainorimproveskillsandfunctioningfordailyliving.
Examplesincludetherapyforachildwhoisn’twalkingortalkingattheexpectedage.Theseservices
mayincludephysicalandoccupationaltherapy,speech-languagepathologyandotherservicesfor
peoplewithdisabilitiesinavarietyofinpatientand/orOutpatientsettings.
HOMEHEALTHCARE
ServicesprovidedbyastatelicensedHomeHealthCareagencyaspartofaprogramforcareand
treatmentinaCoveredPerson'shome.
HOSPICE
Aninstitutionthat:
• ProvidesaHospiceCareProgram;
• Isseparatedfromoroperatedasaseparateunitofahospital,hospital-relatedinstitution,Home
HealthCareagency,mentalhealthfacility,extendedcarefacility,oranyotherlicensedhealth
careinstitution;
• Providescarefortheterminallyill;and
• IslicensedasaHospiceCareProgrambythestateinwhichitoperates.
CCHP17.EOC
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Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
HOSPICECAREPROGRAM
Acoordinated,interdisciplinaryprogramprescribedandsupervisedbyanappropriatePractitionerto
meetthespecialphysical,psychological,andsocialneedsofaterminallyillCoveredPersonandthoseof
hisorherimmediatefamily.
HOSPITAL
AfacilitythatprovidesacutecareorSubacuteMedicalCareforaSicknessoranInjuryonanInpatient
basis.Thistypeoffacilitymayalsobereferredtoasasubacutemedicalfacilityoralongtermacutecare
facilityandmustmeetallofthefollowingrequirements:
• BelicensedbythestateinwhichtheservicesarerenderedandaccreditedbytheJoint
CommissiononAccreditationofHealthcareOrganizations(JCAHO)orMedicaretoprovideacute
careorSubacuteMedicalCare.
• Bestaffedbyanondutyphysician24hoursperday.
• Providenursingservicessupervisedbyanondutyregisterednurse24hoursperday.
• Maintaindailymedicalrecordsthatdocumentallservicesprovidedforeachpatient.
• Provideimmediateaccesstoappropriatein-houselaboratoryandimagingservices.
• NotprimarilyprovidecareforMentalHealthorSubstanceAbuseDisordersalthoughthese
servicesmaybeprovidedinadistinctsectionofthesamephysicalfacility.
• Providecareinanintensivecareunit(ICU),aneonatalintensivecareunit(NICU),acoronary
intensivecareunit(CICU)andstep-downunits.
ILLNESS
ASickness,disease,ordisorderofaCoveredPerson.Illnessdoesnotincludelearningdisabilities,
attitudinaldisorders,ordisciplinaryproblems.AllIllnessesthatexistatthesametimeandthataredue
tothesameorrelatedcausesaredeemedtobeoneillness.Further,ifanIllnessisduetocausesthatare
thesameas,orrelatedto,thecausesofapriorIllness,theillnesswillbedeemedacontinuationor
recurrenceofthepriorillnessandnotaseparateIllness.
INJURY
AccidentalbodilydamagesustainedbyaCoveredPersonandinflictedonthebodybyanexternalforce.
AllInjuriesduetothesameaccidentaredeemedtobeoneInjury.
IN-NETWORKPROVIDER
Aproviderofhealthcareservicesthathasaparticipationagreementineffect(eitherdirectlyor
indirectly)withCCHP.
IN-NETWORKPHARMACY
Apharmacythathasaparticipationagreementineffect(eitherdirectlyorindirectly)withCCHP.
INPATIENT
Medicalservices,supplies,ortreatmentreceivedbyaCoveredPersonwhoisanovernightpatientofa
Hospitalorotherfacility,usingandbeingchargedforroomandboard.
IN-NETWORKBENEFITS
Coveredtreatment,servicesorsuppliesprovidedbyanIn-NetworkProvider.
CCHP17.EOC
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Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
MAXIMUMALLOWEDAMOUNT
ThemaximumamountofthebilledchargefromanIn-NetworkProviderorOut-of-NetworkProvideras
determinedbyUsbaseduponwhatitdeemspayableforCoveredServicesforaCoveredPerson.
ForIn-NetworkProviders,theMaximumAllowedAmountisthereimbursementrate(feeschedule,
discountedamount,diagnosisrelatedgroup,otherpaymentmethodology)thatthePractitionerandUs
haveagreedupon.
ForOut-of-NetworkProviders,theMaximumAllowedAmountisbasedonthelesserof:
• AmountsbilledbyahealthcarePractitioner;or
• Fee(s)thatarenegotiatedwiththeOut-of-NetworkProvider;or
• ForInpatientandoutpatientservices;thecontractedamountpaidtoIn-NetworkProvidersforthe
CoveredService,excludingtheamountofanyCopaymentorCoinsurancethatappliestothe
CoveredServicewhenitisreceivedfromanIn-NetworkProvider.Ifthereismorethanone
contractedamountwithIn-NetworkProvidersfortheCoveredService,theamountisthemedianof
theseamounts;or
• Forallothermedicalandprofessionalservices;apercentage,asdeterminedbyUs,ofthe
publishedratesallowedforthezipcodeinwhichserviceswererenderedbytheCentersfor
MedicareandMedicaidServices(CMS)forMedicareforthesameorsimilarhealthcareservice,or
§ WhenarateisnotpublishedbyCMSforthehealthcareservice,Weusean
availablegapmethodologytodeterminearateforthehealthcareserviceas
follows:
o ForhealthcareservicesotherthanPractitioneradministered
pharmaceuticals,Weuseagapmethodologythatusesarelativevalue
scale,whichisusuallybasedonthedifficulty,time,work,risk,and
resourcesofthehealthcareservice.
o ForPractitioneradministeredpharmaceuticals,Weuseagap
methodologythatissimilartothepricingmethodologyusedbyCMS,
andproducesfeesbasedonpublishedacquisitioncostsoraverage
wholesalepricesforpharmaceuticals.Thismethodologyiscreatedby
Usbasedonaninternallydevelopedpharmaceuticalpricingresource.
o WhenthereisnotanavailableorapplicableCMSrateandagap
methodologydoesnotapplytothehealthcareservice,theMaximum
AllowedAmountisbasedonapercentage,asdeterminedbyUs,ofthe
healthcarePractitioner’scharge.
WeannuallyupdateMaximumAllowedAmountwhenupdateddatafromCMSbecomesavailable.
AmountsusedaretheratesestablishedbyCMSonJanuary1ofthecurrentyear.Updatestothe
MaximumAllowedAmountaretypicallyimplementedwithin30to90daysafterCMSupdatesitsdata.
MAXIMUMOUT-OF-POCKETLIMIT
ThesumoftheDeductibleamount,prescriptiondrugDeductibleamount(ifapplicable),Copayment
amountandCoinsurancepercentageofcoveredexpenses,asshownintheScheduleofBenefits.Afterthe
MaximumOut-Of-PocketAmountismetforanindividual,Wepays100%ofeligibleserviceexpenses.The
familyMaximumOut-Of-PocketAmountistwotimestheindividualMaximumOut-Of-PocketAmount.For
familycoverage,thefamilyMaximumOut-Of-PocketAmountcanbemetwiththecombinationofanyone
CCHP17.EOC
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Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
ormoreCoveredPersons’eligibleserviceexpenses.
ThefollowingdonotcounttowardsatisfyinganyMaximumOut-of-PocketLimit:
• AmountsinexcessoftheMaximumAllowableAmount(balancebilledcharges).
• Thedifferenceincostbetweenabrandnamedrugandwhatwewillpayforagenericdrugwhen
agenericdrugsubstituteexistsbutthebrandnamedrugisdispensed.
• AllOut-of-NetworkProvidercharges,exceptforEmergencyandUrgentCareCopayments.
MEDICALSUPPLIES
Thenon-durabledisposablehealthcarematerialsorderedorprescribedbyaPractitioner,whichis
primarilyandcustomarilyusedtoserveamedicalpurpose. Theycannotbeusedbyanindividualinthe
absenceofIllnessorInjuryorrepeatedlybydifferentindividuals.
MEDICALLYNECESSARY
Anymedicalservice,supplyortreatmentauthorizedbyaPractitionerforpreventiveorscreening
purposesortodiagnoseandtreataCoveredPerson’sIllnessorInjurywhich:
• Isconsistentwiththesymptomsordiagnosis;
• Isprovidedaccordingtogenerallyacceptedmedicalpracticestandards;
• Isnotcustodialcare;
• IsnotsolelyfortheconvenienceofthePractitionerortheCoveredPerson;
• IsnotExperimentalorInvestigationalTreatment;
• Isprovidedinthemostcosteffectivecarefacilityorsetting;
• Doesnotexceedthescope,duration,orintensityofthatlevelofcarethatisneededtoprovide
safe,adequateandappropriatediagnosisortreatment;and
• WhenspecificallyappliedtoaHospitalconfinement,itmeansthatthediagnosisandtreatment
ofYourmedicalsymptomsorconditionscannotbesafelyprovidedasanOutpatient.
ChargesincurredfortreatmentnotMedicallyNecessaryarenoteligibleserviceexpenses.
MENTALHEALTHDISORDER
Abehavioral,emotionalorcognitivepatternoffunctioninginanindividualthatisassociatedwith
distress,suffering,orimpairmentinoneormoreareasoflife–suchasschool,work,orsocialandfamily
interactions-thatislistedinthecurrentDiagnosticandStatisticalManualoftheAmericanPsychiatric
Association,unlessthoseservicesordisordersarespecificallyexcluded.Thefactthatadisorderisliste
intheDiagnosticandStatisticalManualoftheAmericanPsychiatricAssociationdoesnotmeanthat
treatmentofthedisorderisaCoveredService.
OUT-OF-NETWORKPHARMACY
ApharmacywhoisNOTidentifiedinthemostcurrentlistoftheIn-NetworkPharmaciesprovidedby
CCHP. PrescriptionsreceivedfromanOut-of-NetworkPharmacyarenotcovered,exceptasspecifically
statedinthisContract.
OUT-OF-NETWORKPROVIDER
APractitionerorproviderwhoisNOTidentifiedinthemostcurrentlistoftheIn-NetworkProviders
providedbyCCHP.ServicesreceivedfromanOut-of-NetworkProviderarenotcovered,exceptas
specificallystatedinthisContract.
NUTRITIONALPRODUCTS
CCHP17.EOC
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Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
Aliquidsourceofnutrition,whichmaycontainsomeorallofthenutrientsnecessarytomeetminimum
dailynutritionalrequirementsthatisadministeredunderthedirectionofaPractitionerintothe
gastrointestinaltracteitherorallyorthroughatubeorviacatheterinsertedintothesuperiorvenacava
whenYourgastrointestinaltractdoesnotfunctionsufficientlytopermitnormaloralorenteralfeedings.
OUT-OF-NETWORKBENEFITS
Non-Emergency,MedicallyNecessarytreatment,servicesorsuppliesprovidedbyanOut-Of-Network
Providerandtreatment,servicesorsuppliesprovidedbyanIn-NetworkProviderthatarereceived
withoutOurauthorization.
PEDIATRICEYEWEARCOLLECTION
Thecollectionofeyewear,includingglasses,lenses,framesandcontactlensesdesignatedbyOur
EyewearBenefitManagerforcoverageundertheVisionCareServicesprovisionofthisplan.
PERSONALHEALTHINFORMATION
AnypersonalinformationthatiscreatedorreceivedbyCCHPthatrelatestotheCoveredPerson’s
physicalormentalhealthorcondition,treatmentorforpaymentofhealthcareservicesreceivedbythe
CoveredPerson.
PHARMACYBENEFITMANAGER
UsoranentitydesignatedbyUstomaintainpharmacyanddrugBenefits.CallUstoverifythenameof
thePharmacyBenefitManager.
PHARMACEUTICALPRODUCTS
U.S.FoodandDrugAdministration-approvedprescriptionsusedtodiagnose,cure,treatorprevent
disease. PharmaceuticalProductsmustbeadministeredinconnectionwithaCoveredServicebya
PractitionerwithinthescopeofthePractitioner’slicense,andnototherwiseexcludedunderthis
Contract.
PRACTITIONER
Includesbutisnotlimitedtoaphysician,nurseanesthetist,physician'sassistant,physicaltherapist,or
midwife.ThefollowingareexamplesofprovidersthatareNOTmedicalPractitioners,bydefinitionof
thisContract:acupuncturist,speechtherapist,occupationaltherapist,rolfer,registerednurse,hypnotist,
respiratorytherapist,X-raytechnician,emergencymedicaltechnician,socialworker,familycounselor,
marriagecounselor,childcounselor,naturopath,perfusionist,massagetherapistorsociologist.With
regardtomedicalservicesprovidedtoaCoveredPerson,amedicalPractitionermustbelicensedor
certifiedbythestateinwhichcareisrenderedandperformingserviceswithinthescopeofthatlicense
orcertification.
PRIMARYCAREPROVIDER
Familypractice,generalpractice,internalmedicine,pediatrics,geriatrics,OB/GYN,ornursepractitioner
orphysicianassistantpracticinginaPrimaryCareProviderrole.
PRIORAUTHORIZATION
AprocessperformedtodeterminewhethertherequestedtreatmentorserviceisMedicallyNecessary,
thatsuchtreatmentorservicewillbeobtainedintheappropriatesetting,and/orwillbeaCovered
Service.
CCHP17.EOC
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Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
QUALIFIEDHEALTHPLAN(QHP)
AhealthplanthatiscertifiedbytheHealthInsuranceMarketplaceandprovidesessentialhealth
Benefits,followsestablishedlimitsoncost-sharing(likedeductibles,copayments,andout-of-pocket
maximumamounts),andmeetsotherrequirements. CCHPisaQualifiedHealthPlan.
RECONSTRUCTIVEPROCEDURE
Procedureiseithertotreatamedicalcondition,toimproveorrestorephysiologicfunction,orto
improveorrepairanabnormalconditionofabodypartthatistheresultof,orincidentalto,priorInjury,
congenitalanomaly,orapriorsurgerydoneonthatbodypart.
REHABILITATIVESERVICES
SpecializedtreatmentforaSicknessoranInjurywhichmeetsallofthefollowingrequirements:
• Isaprogramofservicesprovidedbyoneormoremembersofamulti-disciplinaryteam.
• Isdesignedtoimprovethepatient’sfunctionandindependence.
• IsunderthedirectionofaqualifiedhealthcarePractitioner.
• Includesaformalwrittentreatmentplanwithspecificattainableandmeasurablegoalsand
objectives.
• MaybeprovidedineitheranInpatientorOutpatientsetting.
RETAILHEALTHCLINIC
Afacilitythatmeetsallofthefollowingrequirements:
• Islicensedbythestateinaccordancewiththelawsforthespecificservicesbeingprovidedin
thatfacility;
• IsstaffedbyaPractitionerinaccordancewiththelawsofthatstate;
• Isattachedtoorpartofastoreorretailfacility;
• IsseparatefromaHospital,emergencyroom,RehabilitationFacility,Free-standingFacility,
SkilledNursingFacility,SubacuteMedicalRehabilitationFacility,orUrgentCareFacility,andany
Practitioner’sofficelocatedtherein,evenwhenservicesareperformedafternormalbusiness
hours;
• ProvidesgeneralmedicaltreatmentorservicesforaSicknessorInjury,orprovidespreventive
medicineservices;
• Doesnotprovideroomandboardorovernightservices;and
• DoesnotincludeTelehealthServicesorTelemedicineServices.
SERVICEAREA
Ageographicalarea,madeupofcounties,wherewehavebeenauthorizedbytheStateofWisconsinto
sellandmarketOurhealthplans.ThisiswhereOurIn-NetworkProvidersarelocatedwhereyouwill
receiveallofYourhealthcareservicesandsupplies.Youcanreceivepreciseserviceareaboundaries
fromOurwebsiteorOurCustomerServicedepartment.
SICKNESS
AphysicalIllnessordisease.
SKILLEDNURSINGFACILITY
AfacilitythatprovidescontinuousskillednursingservicesonanInpatientbasisforpersonsrecovering
fromaSicknessoranInjury.Thefacilitymustmeetallofthefollowingrequirements:
• Belicensedbythestatetoprovideskillednursingservices.
• Bestaffedbyanoncallphysician24hoursperday.
CCHP17.EOC
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Definitions
TERMSANDDEFINITIONSTOHELPYOUUNDERSTAND
YOURCOVERAGE
•
•
•
Provideskillednursingservicessupervisedbyanondutyregisterednurse24hoursperday.
Maintaindailyclinicalrecords.
Notprimarilybeaplaceforrest,fortheagedorforcustodialcareorprovidecarefor
MentalHealthorSubstanceAbuseDisordersalthoughtheseservicesmaybeprovidedina
distinctsectionofthesamephysicalfacility.Thefacilitymayalsoprovideextendedcareor
custodialcarewhichwouldnotbecoveredunderthisContract.
SUBACUTEMEDICALCARE
Ashort-termcomprehensiveInpatientprogramofcareforaCoveredPersonwhohasaSicknessoran
Injurythat:
• DoesnotrequiretheCoveredPersontohaveaprioradmissionasanInpatientinalicensed
medicalfacility;and
• Doesnotrequireintensivediagnosticand/orinvasiveprocedures;and
• RequiresPractitionerdirection,intensivenursingcare,significantuseofancillaries,andan
outcome-focused,interdisciplinaryapproachusingaprofessionalmedicalteamtodeliver
complexclinicalinterventions.
SUBACUTEMEDICALREHABILIATIONFACILITY
AfacilitythatprovidesSubacuteMedicalCareforRehabilitativeServicesforaSicknessoranInjuryonan
Inpatientbasis.Thistypeoffacilitymustmeetallofthefollowingrequirements:
• BelicensedbythestateinwhichtheservicesarerenderedtoprovideSubacuteMedical
• CareforRehabilitativeServices.
• Bestaffedbyanoncallphysician24hoursperday.
• Providenursingservicessupervisedbyanondutyregisterednurse24hoursperday.
• NotprimarilyprovidecareforMentalHealthorSubstanceAbuseDisordersalthoughthese
servicesmaybeprovidedinadistinctsectionofthesamephysicalfacility.Thefacilitymayalso
provideextendedcareorcustodialcarewhichwouldnotbecoveredunderthisplan.
SUBSTANCEUSEDISORDER
Alcohol,drugorchemicalabuse,overuseordependencydisorderslistedinthecurrentDiagnosticand
StatisticalManualoftheAmericanPsychiatricAssociation,unlessthoseservicesordisordersare
specificallyexcluded.ThefactthatadisorderislistedintheDiagnosticandStatisticalManualofthe
AmericanPsychiatricAssociationdoesnotmeanthattreatmentofthedisorderisaCoveredService.
URGENTCARE
TreatmentorservicesprovidedforaSicknessoranInjurythatdevelopssuddenlyandunexpectedlythat
requiresimmediatetreatment,butisnotofsufficientseveritytobeconsideredEmergencytreatment.
URGENTCAREFACILITY
AfacilitythatprovidesforthedeliveryofUrgentCareservices.AnUrgentCareFacilitygenerally
providesunscheduled,walk-incare.AnUrgentCareFacilitymaybeHospital-basedornon-Hospital
based.
WE,US,OUR,OURS
Children’sCommunityHealthPlanoritsAdministrator.
YOU,YOUR,YOURS,YOURSELF
ThepersonlistedastheContractHolder.
CCHP17.EOC
30
Definitions
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
AMBULANCESERVICES
Emergencyambulancetransportationbyalicensedambulanceservice(eithergroundorairambulance)
isprovidedtothenearestHospitalwhereEmergencyHealthServicescanbeperformed.
Non-Emergencyambulancetransportationbyalicensedambulanceservice(eithergroundorair
ambulance,asWedetermineappropriate)betweenfacilitieswhenthetransportisanyofthefollowing:
• FromanOut-of-NetworkHospitaltoanIn-NetworkHospital.
• ToaHospitalthatprovidesahigherlevelofcarethatwasnotavailableattheoriginalHospital.
• Toamorecost-effectiveacutecarefacility.
• Fromanacutefacilitytoasub-acutesetting.
AUTISMSPECTRUMDISORDER
CoverageisprovidedforthefollowingwhenprescribedbyaPractitioner:
AUTISMINTENSIVELEVELSERVICES
Benefitsareprovidedforevidence-basedbehavioralintensive-leveltherapyforaCoveredPersonwitha
verifieddiagnosisofAutismSpectrumDisorder,themajorityofwhichshallbeprovidedtotheenrolled
Dependentchildwhentheparentorlegalguardianispresentandengaged.Theprescribedtherapymust
beconsistentwithallofthefollowingrequirements:
• BaseduponatreatmentplandevelopedbyaqualifiedPractitionerthatincludesatleast20
hoursperweekoverasix-monthperiodoftimeofevidence-basedbehavioralintensive
therapy,treatmentandserviceswithspecificcognitive,social,communicative,self-care,or
behavioralgoalsthatareclearlydefined,directlyobservedandcontinuallymeasuredandthat
addressthecharacteristicsofautismspectrumdisorders.Treatmentplansshallrequirethatthe
enrolledDependentchildbepresentandengagedintheintervention.
• ImplementedbyqualifiedPractitioners,qualifiedsupervisingPractitioners,qualified
professional,qualifiedtherapistsorqualifiedparaprofessionals.
• ProvidedinanenvironmentmostconducivetoachievingthegoalsoftheenrolledDependent
child’streatmentplan.
• Includedtrainingandconsultation,participationinteammeetingandactiveinvolvementofthe
enrolledDependentchild’sfamilyandtreatmentteamforimplementationofthetherapeutic
goalsdevelopedbytheteam.
• TheenrolledDependentchildisdirectlyobservedbythequalifiedPractitioneratleastonce
everytwomonths.
• BeginningaftertheenrolledDependentchildistwoyearsofageandbeforetheenrolled
Dependentchildisnineyearsofage.
IntensiveLevelServiceswillbecoveredforuptofourcumulativeyears.CCHPmaycreditagainstany
previousIntensiveLevelServicestheenrolledDependentchildreceivedagainsttherequiredfouryears
ofIntensiveLevelServicesregardlessofpayer.CCHPmayalsorequiredocumentationincludingmedical
recordsandtreatmentplanstoverifyanyevidence-basedbehavioraltherapytheDependentchild
receivedforautismspectrumdisordersthatwasprovidedtotheenrolledDependentchildpriorto
attainingnineyearsofage.Evidence-basedbehavioraltherapythatwasprovidedtotheenrolled
CCHP17.EOC
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
Dependentchildforanaverageof20ormorehoursperweekoveracontinuoussix-monthperiodis
consideredtobeintensive-levelservices. AUTISMNON-INTENSIVELEVELSERVICES
Non-intensiveLevelServiceswillbecoveredforanenrolledDependentchildwithaverifieddiagnosisof
AutismSpectrumDisorderthatareevidence-basedandareprovidedbyaqualifiedPractitioner,
professional,therapistorparaprofessionalineitherofthefollowingconditions:
• AfterthecompletionofIntensiveLevelServicesanddesignedtosustainandmaximizegains
madeduringintensivelevelservicestreatment.
• ToanenrolledDependentchildwhohasnotandwillnotreceiveIntensiveLevelServicesbutfor
whomnon-intensivelevelserviceswillimprovetheenrolledDependentchild’scondition.
Benefitswillbeprovidedforevidence-basedtherapythatisconsistentwithallofthefollowing
requirements:
• BaseduponatreatmentplandevelopedbyaqualifiedPractitioner,supervisingPractitioner,
professionalortherapistthatincludesspecifictherapygoalsthatareclearlydefined,directly
observedandcontinuallymeasuredandthataddressthecharacteristicsofautismspectrum
disorders.TreatmentplansshallrequirethattheenrolledDependentchildbepresentand
engagedintheintervention.
• ImplementedbyqualifiedPractitioners,qualifiedsupervisingPractitioners,qualified
professionals,qualifiedtherapistorqualifiedparaprofessionals.
• ProvidedinanenvironmentmostconducivetoachievingthegoaloftheenrolledDependent
child’streatmentplan.
• Includedtrainingandconsultation,participationinteammeetingsandactiveinvolvementofthe
enrolledDependentchild’sfamilyinordertoimplementthetherapeuticgoalsdevelopedbythe
team.
• ProvidedsupervisionofPractitioners,professionals,therapistsandparaprofessionalsby
qualifiedsupervisingPractitionersonthetreatmentteam.
Non-IntensiveLevelServicesmayincludedirectorconsultativeserviceswhenprovidedbyqualified
Practitioners,qualifiedsupervisingPractitioners,qualifiedprofessionals,qualified
paraprofessionals,orqualifiedtherapists.
ForbothIntensiveLevelandNon-IntensiveLevelServices:
• CCHPrequiresthatprogressbeassessedanddocumentedthroughoutthecourseoftreatment.
WemayrequestandreviewtheenrolledDependentchild’streatmentplanandthesummaryof
progressonaperiodicbasis.
• TraveltimeforqualifiedPractitioners,qualifiedsupervisingPractitioners,qualifiedprofessional,
qualifiedtherapistsorqualifiedparaprofessionalsinnotincludedwhencalculatingthenumber
ofhoursofcareprovidedperweek.Wearenotrequiredtoreimbursefortraveltime.
• WemayrequireaCoveredPersontoobtainasecondopinionfromanotherhealthcare
PractitioneratOurexpense.ThisPractitionermustbeexperiencedintheuseofempirically
validatedtoolsspecificforAutismSpectrumDisorders. TheCoveredPerson,theCovered
Person‘sparentsortheCoveredPerson’sauthorizedrepresentativeandCCHPmustagreeupon
thePractitioner.Coverageforthecostofthesecondopinionwillbeinadditiontothebenefit
mandatedbySection632.895,WisconsinStatutes,asamended.
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
IntensiveLevelandNon-IntensiveLevelServicesincludebutarenotlimitedtospeech,occupationaland
behavioraltherapies.PriorAuthorizationisrequiredforAutismSpectrumDisorderservices.
BREASTRECONSTRUCTION
Benefitsareavailableforbreastreconstructionrelatedtoacoveredmastectomywhichincludes:
• Reconstructionofthebreastonwhichthemastectomywasperformed.
• Surgeryandreconstructionoftheotherbreasttoproduceanevenappearance.
• Prosthesisandtreatmentofphysicalcomplicationsatallstagesofthemastectomy
CHIROPRACTICCARE
BenefitsareavailableforChiropracticCareprovidedbyaDoctorofChiropracticmedicinewhen
renderedwithinthescopeofthechiropracticlicense.CoveredServicesincludediagnostictesting,
manipulationsandtreatment.
CLINICALTRIALS
RoutinepatientcarecostsincurredduringparticipationinaClinicalTrial.
Routinepatientcostsincludesitems,services,anddrugsprovidedtoYouinconnectionwithaClinical
TrialthatwouldbecoveredunderthisPlanifYouwerenotenrolledinsuchqualifiedClinicalTrial.In
ordertoqualifyYoumustbeeligibletoparticipateintheClinicalTrialaccordingtothetrialprotocolwith
respecttotreatmentofcancerorotherlife-threateningdiseaseorcondition,andeither:
• thereferringIn-NetworkProviderhasconcludedthatYourparticipationintheClinicalTrialis
appropriateaccordingtothetrialprotocolor,
• Youand/orYourPractitionerprovidemedicalandscientificinformationestablishingthatYour
participationintheClinicalTrialisappropriateaccordingtothetrialprotocol.
Routinepatientcaredoesnotincludetheinvestigationalitem,device,orservice,itself;itemsand
servicesprovidedsolelytosatisfydatacollectionandanalysisneedsandthatarenotusedinYourdirect
clinicalmanagement;and/oraservicethatisclearlyinconsistentwithwidelyacceptedandestablished
standardsofcareforYourdiagnosis.
COCHLEARIMPLANTS
Benefitsareavailableforthefollowing:
• Thecostofcochlearimplantsthatareprescribedbyaphysicianorbyalicensedaudiologistfora
CoveredPersonunderthiswhoiscertifiedasdeaforhearingimpairedbyaphysicianora
licensedaudiologist.
• Thecostoftreatmentrelatedtocochlearimplants,includingproceduresfortheimplantationof
cochleardevices.
• ThecostofcochlearimplantsmaynotexceedthecostofoneimplantperearperCovered
Personmorethanonceeverythreeyears.
CONTRACEPTIVECOVERAGEANDFAMILYPLANNING
BenefitsforcontraceptivecoverageandfamilyplanningincludecoverageforallFDA-approved
contraceptivemethods.Thisincludes:
• Oralcontraceptivemedications.
• InsertionandremovalofFDA-approvedcontraceptivedevices(forexample,theIUD).
• Flexiblebirthcontrolvaginalring.
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
•
•
•
•
Contraceptivepatch.
Injectedcontraceptives(forexample,theDepo-Proverashot).
Voluntarysterilizationservices,includingtuballigationandvasectomy.*
PregnancytestingperformedinamedicalclinicorHospital.
BenefitsforcontraceptivecoverageforCoveredPersonsarenotsubjecttoCoinsurance,Copaymentor
Deductible.
*Notethatwedonotcoverthereversalofsterilizationservices.
DENTALSERVICES—ACCIDENTONLY
Benefitsareavailablefortreatmentofaccidentaldamagetotheteethand/orgumsandmustconform
tothefollowing:
• DentalservicesarereceivedfromaDoctorofDentalSurgery,OralSurgeonorDoctorofMedical
Dentistry.
• Treatmentisstartedwithinthreemonthsoftheaccident,unlessextenuatingcircumstances
exist(suchasprolongedhospitalizationorthepresenceoffixationwiresfromfracturecare).
• Treatmentmustbecompletedwithin12monthsoftheaccident.
• BenefitsfortreatmentofaccidentalInjuryarelimitedtothefollowing:
o Emergencyexamination.
o NecessarydiagnosticX-rays.
o Temporarysplintingofteeth.
o Extractions.
o Endodontic(RootCanal)treatment.
o Prefabricatedpostandcore.
o Anesthesia.
o Post-traumaticcrownsifsucharetheonlyclinicallyacceptabletreatment.
o ReplacementoflostteethduetotheInjurybyimplant,denturesorbridges.
Pleasenotethatdentaldamagethatoccursasaresultofnormalactivitiesofdailylivingorextraordinary
useoftheteethisnotconsideredhavingoccurredasanaccident.Benefitsarenotavailableforrepairsto
teeththataredamagedasaresultofsuchactivities.
DENTAL/ANESTHESIASERVICES
BenefitsareavailableforHospitalorambulatorysurgerycenterservices,includinganesthetics,for
dentalcarefurnishedinthefacility,ifanyofthefollowingapplies:
• TheCoveredPersonhasachronicdisabilityasdefinedbyapplicablestatelaw;
• TheCoveredPersonhasamedicalconditionthatrequireshospitalizationorgeneralanesthesia
fordentalcare.
PriorAuthorizationoftheseservicesisrequiredinadvance.
DIABETESSERVICES
Benefitsfordiabetesservicesincludebutarenotlimitedto:
• DiabetesOutpatientself-managementtraining,education,medicalnutritiontherapyservices.
ThesemustbeorderedbyaPractitionerandprovidedbyappropriatelylicensedorregistered
healthcareprofessionals.
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
•
•
•
•
Medicaleyeexaminations(dilatedretinalexaminations)andpreventivecarefortreatmentof
Diabetes.
Insulin,insulinsyringeswithneedles,insulinpens,glucometers,teststrips,alcohol,lancetsand
lancetdevices.
MedicallyNecessaryroutinefootcare.
Insulinpumps.
PriorAuthorizationisrequiredforinsulininfusionpumps.
DIAGNOSTICSERVICES
CoverageforDiagnosticServicesincludesbutisnotlimitedto:
• X-rayandotherradiologyservices,includingmammogramsforanypersondiagnosedwith
breastdisease.
• MagneticResonanceAngiography(MRA).
• MagneticResonanceImaging(MRI).
• CATscan.
• Laboratoryandpathologyservices.
• Cardiographic,encephalographic,andradioisotopetests.
• Nuclearcardiologyimagingstudy.
• Ultrasoundservice.
• Allergytest.
• Electrocardiogram(EKG).
• Electromyogram(EMG)exceptthatsurfaceEMG’sarenotCoveredServices.
• Echocardiogram.
• Bonedensitystudy.
• Positronemissiontomography(PETscan).
• DiagnosticTestsasanevaluationtodeterminetheneedforacoveredtransplantprocedure.
• Dopplerstudy.
• Brainstemauditoryevokedpotential(BAER).
• Somatosensoryevokedpotential(SSEP).
• Visualevokedpotential(VEP).
• Nerveconductionstudy.
• Muscletest.
• Electrocorticogram.
• Centralsupply(IVtubing)orpharmacy(dye)necessarytoperformtestsarecoveredaspartof
thetest,whetherperformedinaHospitalorphysician’soffice.
PriorAuthorizationrequiredforPETscans.
CertainDiagnosticServicesarecoveredasPreventiveCareServices.Seethatsectionforadditional
information.
DURABLEMEDICALEQUIPMENTANDSUPPLIES
BenefitsunderthissectionincludeMedicallyNecessaryDurableMedicalEquipmentprescribedbya
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COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
Practitioner.
IfmorethanonepieceofDurableMedicalEquipmentcanmeetYourfunctionalneeds,Benefitsare
availableonlyfortheequipmentthatmeetstheminimumspecificationsforYourneeds.
ExamplesofDurableMedicalEquipmentinclude:
• Equipmenttoassistmobility,suchasawheelchair,walker,crutches,orcane.
• AstandardHospital-typebed.
• Oxygenandtherentalofequipmenttoadministeroxygen(includingtubing,connectorsand
masks).
• Deliverypumpsfortubefeedings(includingtubingandconnectors).
Negativepressurewoundtherapypumps(woundvacuums).
• Braces,includingnecessaryadjustmentstoshoestoaccommodatebraces.
• Bracesthatstabilizeaninjuredbodypartandbracestotreatcurvatureofthespine.(Bracesthat
straightenorchangetheshapeofabodypartareorthoticdevices,andareexcludedfrom
coverage.Dentalbracesarealsoexcludedfromcoverage.)
• Mechanicalequipmentnecessaryforthetreatmentofchronicoracuterespiratoryfailure
(exceptthatair-conditioners,humidifiers,dehumidifiers,airpurifiersandfiltersandpersonal
comfortitemsareexcludedfromcoverage).
• Burngarments.
• InsulinpumpsandallrelatednecessarysuppliesasdescribedunderDiabetesServices.
• Externalcochleardevicesandsystems.Benefitsforcochlearimplantationareprovidedunder
theapplicablemedical/surgicalBenefitcategoriesinthisContract,asrequiredbyWisconsin
insurancelaw.
• CPAPmachine
• Nebulizer.
• Orthoticappliancesthatstraightenorre-shapeabodypart,forscoliosisinchildren.
• Speechaiddevicesandtracheo-esophagealvoicedevicesrequiredfortreatmentofsevere
speechimpedimentorlackofspeechdirectlyattributedtoSicknessorInjury.Benefitsforthe
purchaseofspeechaiddevicesandtracheo-esophagealvoicedevicesareavailableonlyafter
completingarequiredthree-monthrentalperiod.BenefitsarelimitedasstatedintheSchedule
ofBenefits.
Benefitsunderthissectionmustfollowevidence-basedpractice.
Benefitsunderthissectiondonotincludeanydevice,appliance,pump,machine,stimulator,ormonitor
thatisfullyimplantedintothebody.
CCHPwilldecideiftheequipmentshouldbepurchasedorrented. PriorAuthorizationisrequiredfora
retailpurchaseprice$500orgreaterforanysingleitemwhetherapurchasepriceoramonthlyrental
price.
Benefitsareavailableforrepairsandreplacement,exceptthat:
• Benefitsforrepairandreplacementdonotapplytodamageduetomisuse,maliciousbreakage
orgrossneglect.
• Benefitsarenotavailabletoreplacelostorstolenitems.
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
EMERGENCYHEALTHSERVICES—OUTPATIENT
BenefitswillbecoveredforservicesthatarerequiredtostabilizeorinitiatetreatmentinanEmergency.
Benefitsunderthissectionincludethefacilitycharge,suppliesandallprofessionalservicesrequiredto
stabilizeYourconditionand/orinitiatetreatment. Ambulatorynon-emergent,non-urgentfollow-upcaretoEmergencyHealthServicesarecovered
BenefitsiffurnishedbyanIn-NetworkProviderorPractitioner.
IfEmergencymedicalconditiontreatmentisatanOut-of-NetworkProviderfacility,onceYouarestable
WewillseektohaveyoutransferredtoanIn-NetworkProviderfacility.IfYouarenottransferredtoan
In-NetworkProviderfacility,Wewillcoordinateyourcarewiththehospitalandphysicians.
BenefitswillnotbepaidandYoumaybeliableforchargesforcarefurnishedoutsidetheServiceArea
fortheCoveredPerson’sconvenience.Thisincludes,forexample,non-Emergency,non-UrgentCarefor
CoveredPersonswholiveoutsideofCCHP’sServiceArea.
WedonothavecontractswithOut-of-NetworkProvidersandthereforehavenocontrolovercosts,
billingand/orcodingpracticesand/orthequalityoftreatments,servicesandsuppliesprovidedbyan
Out-of-NetworkProvider.Thismayresultinadditionalout-of-pocketexpenses.SeeMaximum
AllowedAmountformoredetails.
ENTERALNUTRITIONINTHEHOME
CCHPcoversNutritionalProductsthatarespecialtyfoodproductswhenMedicallyNecessaryandwhen
underthedirectionofaphysicianonanoutpatientbasis,forthetreatmentofinbornerrorsof
metabolismandsomehereditarymetabolicorders.Thesedisordersare:Phenylketonuria(PKU),
Branch-chainketonuria,Galactosemia,Homocysteinuria,Allergicreactionormalabsorptionsyndromes,
specificallyhemorrhagiccolitis.
Coverageisindependentofwhethertheproductisadministeredorallyorenterally.
NutritionalProductsprescribedtomeetnutritionalneedsthatcanbemetusingshelfnutritional
productstotheextentthattheyarecommonlyavailableintheretailgrocerymarket,willnotbe
covered,evenwhentheyarethesolesourceofnutrition.
GENETICTESTINGANDCOUNSELING
BenefitsareavailableforGeneticTestingandGeneticCounselingifitisnotExperimentalorInvestigational
Treatment.PriorAuthorizationisrequired.
HABILITATIVESERVICES
AllofthefollowingmustbemetforcoverageofHabilitativeServicesnotrelatedtoAutismSpectrum
Disorder:
• Treatmentmustbeevidence-basedspeech,physicaloroccupationaltherapyprovidedbyan
appropriatelylicensedtherapistunderthedirectionofaphysicianoradvancedpracticenursein
accordancewithawrittentreatmentplanestablishedorcertifiedbythetreatingphysicianor
advancedpracticenurse.
• Oneofthefollowingdiagnoses:
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
•
•
o developmentaldelay
o developmentalcoordinationdisorder
o mixeddevelopmentaldisordero
developmentalspeechorlanguagedisorder
HabilitativeServicesanddiagnosesnotspecificallylistedabovearenotcovered,includingbut
notlimitedtorespitecare,daycare,recreationalcare,residentialtreatment,socialservices,
custodialcare,oreducationservicesofanykind.
CoverageforHabilitativeServiceswillceasewhenmeasurableandsignificantprogresstoward
expectedandreasonableoutcomeshasbeenachievedorhasplateauedasdeterminedbyUs.
BenefitsforHabilitativeServicesinclude:
• PhysicalTherapy,20visitspercalendaryear.
• OccupationalTherapy,20visitspercalendaryear.Thisdoesnotincludeservicesasdescribed
underAutismSpectrumDisorderServices.
• SpeechTherapy,20visitspercalendaryear.Thisdoesnotincludeservicesasdescribedunder
AutismSpectrumDisorderServicesinthissection. PleasenotethatCCHPwillpayBenefitsfor
SpeechTherapyforthetreatmentofdisordersofspeech,language,voice,communicationand
auditoryprocessing.ForspeechtherapywithrelationtoAutismSpectrumDisorders,please
refertotheservicesdescribedunderAutismSpectrumDisorderServicesinthissection.
HEARINGAIDS
Benefitsareavailableforhearingaids,forCoveredPersonswhoarecertifiedasdeaforhearingimpaired
byeitheraphysicianoraudiologistlicensedunderWisconsinlaw.Relatedtreatmentincludesservices,
diagnoses,surgery,andtherapyprovidedinconnectionwiththehearingaidand/orcochlearimplant.
CoverageofhearingaidsissubjecttothelimitlistedintheScheduleofBenefits.Pleasenotethat
CoveredServicesdonotincludethecostofbatteriesorcords.
Benefitsforhearingservicesarelimitedtoonehearingaidpereareverythreeyears.
Benefitsunderthissectiondonotincludeboneanchoredhearingaids.Boneanchoredhearingaidsarea
CoveredServiceforwhichBenefitsareavailableundertheapplicablemedical/surgicalCoveredServices
categoriesinthisContract,onlyforCoveredPersonswhohaveeitherofthefollowing:
• Craniofacialanomalieswhichprecludetheuseofawearablehearingaid.
• Hearinglossofsufficientseveritythatitwouldnotbeadequatelyremediedbyawearable
hearingaid.
BoneanchoredhearingaidsarelimitedtooneperlifetimeandrequirePriorAuthorization.
HOMEHEALTHCARE
BenefitsareavailableforHomeHealthCareservicesonlywheneachofthefollowingapplies:
• AformalhomecareprogramfurnishestheservicesinYourhome;
• TheservicesprovidedareskillednursingorRehabilitativeServices;
• ANetworkPractitionerorders,supervisesandreviewsthecareeverytwomonths.
• ThePractitionermaydeterminethatalongerperiodbetweenreviewsissufficient;
• HospitalizationorconfinementinaSkilledNursingFacilitywouldbenecessaryifHomeHealth
Careserviceswerenotprovided;
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
• TheservicesareMedicallyNecessary.
HomeHealthCareislimitedto60visitsinacalendaryear.Eachconsecutivefour-hourperiodthata
homehealthaideprovidesservicesisonevisit.ServicesarecoveredonlywhenprovidedintheService
Area.
PriorAuthorizationisrequiredforHomeHealthCareservices
Physical,occupationalandspeechtherapyrenderedinthehomewillapplytotheHomeHealthCare
visitmaximum.NursingorRehabilitativeServicesmaybepalliativecareaslongastheservicesarenot
custodial.Aservicewillnotbedeterminedtobe“skilled”nursingorrehabilitationsimplybecausethere
isnotanavailablecaregiver.
HOSPICECARE
HospicecareiscoverediftheCoveredPerson’sPractitionercertifiesthattheYouorYourCovered
Dependent’slifeexpectancyissixmonthsorless;
• Thecareispalliative;and
• TheHospicecareisreceivedfromalicensedHospiceagency;
• ServicesmaybefurnishedinaHospicefacilityhousedinaHospital,aseparateHospiceunitorin
Yourhome.AHospicefacilityhousedinaHospitalmustbe,inaseparateanddistinctarea;
• Hospicecareservicesareprovidedaccordingtoawrittencaredeliveryplandevelopedbya
HospicecarePractitionerandbytherecipientoftheHospicecareservices.
Hospicecareservicesincludebutarenotlimitedto:physicianservices;nursingcare;respitecare;
medicalandsocialworkservices;counselingservices;nutritionalcounseling;painandsymptom
management;medications,medicalsuppliesandDurableMedicalEquipment;occupational,
physical,orspeechtherapies;volunteerservices;HomeHealthCareservices;andbereavement
services.
Respitecaremaybeprovidedonlyonanoccasionalbasis(onceper60Days)andmaynotbereimbursed
formorethanfiveconsecutivedaysatatime.
PriorAuthorizationisrequiredforHospicecareserviceswhetherinhomeorrespitecare.
HOSPITAL—INPATIENTSTAY
BenefitsforservicesandsuppliesprovidedduringanInpatientStayinaHospitalareavailablefor:
• Roomandboardinasemi-privateroom(aroomwithtwoormorebeds)oraroominaspecial
careunit.
• AncillaryServicesandsuppliesreceivedduringtheInpatientstayincludingoperating,delivery
andtreatmentrooms,equipment,prescriptiondrugs,diagnosticandtherapyservices
• PhysicianservicesforInpatientcareincludingbutnotlimitedtoradiologists,
anesthesiologists,pathologistsandEmergencyroomphysicians.
INPATIENTREHABILITATION
BenefitsavailableforCoveredPersonswhen:
• Individualhasanew(acute)medicalconditionoranacuteexacerbationofachroniccondition
thathasresultedinasignificantdecreaseinfunctionalabilitysuchthattheycannotadequately
recoverinalessintensivesetting;and
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
•
•
•
•
Individual'soverallmedicalconditionandmedicalneedseitheridentifyariskformedical
instabilityorarequirementforphysicianandothermedicalprofessionalinvolvement
generallynotavailableoutsidetheHospitalInpatientsetting;and
Theindividualiscapableofactivelyparticipatinginarehabilitationprogramforaminimumof3
hours,asevidencedbyamentalstatusdemonstratingresponsivenesstoverbal,visual,and/or
tactilestimuliandabilitytofollowsimplecommands;and
Individual'smentalandphysicalconditionpriortotheIllnessorInjuryindicatesthereis
significantpotentialforimprovement;and
ThenecessaryRehabilitativeServicesareprescribedbyaphysician,requireclosemedical
supervision,skillednursingcarewiththe24-houravailabilityofanurse,aphysicianwhoare
skilledintheareaofrehabilitationmedicineandiscomingfromaHospital.
PriorAuthorizationisrequired.
KIDNEYDISEASESERVICES
BenefitscoverMedicallyNecessaryservicesforrenalfailure.
Coverageincludes:
o Dialysis;
o Transplantation;and
o ServicesrelatedtodonationwhenrecipientisaCCHPCoveredPerson.
PriorAuthorizationisrequiredfordialysisandtransplantationservices.
LABORATORYSERVICES
Benefitsavailablefordiagnosticpurposesincludelabtestswhenanappropriatediagnosisispresent.All
servicesmustbeorderedbyalicensedPractitioner.Laboratorytestsforpreventivecarearedescribed
underPreventiveCareServices.
MEDICALSUPPLIES
Benefitsunderthissectioninclude:
• TubingsandmaskswhenusedwithapprovedandcoveredDurableMedicalEquipmentas
describedundertheDurableMedicalEquipmentsection.
• DiabeticSupplies.
• OstomySupplies-Pouches,faceplatesandbelts,Irrigationsleeves,bagsandostomyirrigation
cathetersandskinbarriers.Benefitsarenotavailablefordeodorants,filters,lubricants,tape,
appliancecleaners,adhesive,adhesiveremover,orotheritemsnotlistedabove.
• UrinaryCatheters-asdescribedundertheUrinaryCatheter(IntermittentandIndwelling)section.
MENTALHEALTHANDSUBSTANCEUSEDISORDERS
Coveredservicesformentalhealthandsubstanceusedisorderareincludedonanon-discriminatory
basisforallCoveredPersonsforthediagnosisandMedicallyNecessaryandactivetreatmentofmental,
emotional,and/orsubstanceusedisordersasdefinedinthemostrecenteditionoftheDiagnosticand
StatisticalManualofMentalDisordersoftheAmericanPsychiatricAssociation.Diagnosesknownas“V
Codes”areeligibleserviceexpensesonlywhenbilledasasupportingdiagnosis.
CoveredInpatient,IntermediateandOutpatientMentalHealthand/orSubstanceUseDisorderServices
areasfollows:
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
•
•
•
Inpatient
o Inpatienttreatment;
o Observation;
o CrisisStabilization;and
o ElectroconvulsiveTherapy(ECT).
Intermediate
o PartialHospitalizationProgram(PHP);
o DayTreatment
o IntensiveOutpatientProgram(IOP),whichmaybeprovidedinthecommunityorduring
placementinresidentialtreatment.
Outpatient
o Traditionaloutpatientservices,includingindividualandgrouptherapyservices;
o Diagnostictesting;
o Medicationmanagementservices;
o Psychologicaltesting.
Allrespectiveservicesmustbeprovidedbyalicensedmentalhealthprofessional. Theterm“mental
healthprofessional”asusedinreferencemeans:
• Alicensedphysicianwhohascompletedaresidencyinpsychiatryinanoutpatienttreatment
facilityorthephysician’soffice.
• Alicensedpsychologist.
• Alicensedmentalhealthprofessionalpracticingwithinthescopeofhisorherlicense.
Expensesfortheseservicesarecovered,ifMedicallyNecessaryandmaybesubjecttoPrior
Authorization.PleaseseeYourScheduleofBenefitsformoreinformationregardingservicesthat
requirePriorAuthorization.
CoveragewillbeprovidedformentalhealthclinicalassessmentsofDependentfull-timestudents
attendingschoolintheStateofWisconsinbutoutsideoftheServiceArea.Theclinicalassessmentmust
beconductedbyaPractitionerdesignatedbythementalhealth/substanceusedesigneeandwhois
locatedintheStateofWisconsinandinwithin50milesproximitytothefull-timestudent’sschool.If
outpatientmentalhealth/substanceusedisorderservicesarerecommended,coveragewillbeprovided
foramaximumof5visitsatanoutpatienttreatmentfacilityorotherPractitionerdesignatedbythe
mentalhealth/substanceusedesignee,thatislocatedintheStateofWisconsinandinreasonablyclose
proximitytothefull-timestudent’sschool.Coveragefortheoutpatientserviceswillnotbeprovided,if
therecommendedtreatmentwouldprohibittheDependentfromattendingschoolonaregularbasisor
iftheDependentisnolongerafull-timestudent.
WewillprovidecoverageforservicesthatarerequiredbyWis.Stat.609.65,toapersonexamined,
evaluated,ortreatedforaMentalHealthDisorderpursuanttoanemergencydetention,acommitment,
oracourtorder.
MEDICALNUTRITIONEDUCATION
Benefitsunderthissectionareavailableforpeoplewhohavediabetesorgestationaldiabetes,are
pregnantwithweightdisorders,haveobesity,havecancer,diagnosedasfailuretothrive,haveeating
disordersorhaveinbornerrorsofmetabolism. Benefitsarelimitedtothreesessions.
CCHP17.EOC
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
Benefitsunderthissectionincludemedicalnutritionaleducationservicesthatareprovidedby
appropriatelylicensedorregisteredhealthcareprofessionalswhenbothofthefollowingaretrue:
• Nutritionaleducationisrequiredforadiseaseinwhichpatientself-managementisanimportant
componentoftreatment.
• Thereexistsaknowledgedeficitregardingthediseasewhichrequirestheinterventionofa
trainedhealthprofessional.
OUTPATIENTSERVICES
BenefitswillcoveroutpatientservicesthatareperformedbyanIn-NetworkProvider.CCHPwillonlypay
forservicesthatareMedicallyNecessary.
Benefitsunderthissectioninclude:
• Outpatientsurgery.
• Endoscopicprocedures.
• Therapeutictreatmentsincludingdialysis(bothhemodialysisandperitonealdialysis),
chemotherapy(bothoralandintravenous)orotherintravenousinfusiontherapyand
radiationoncology.
• Painmanagementprocedures.
Electivesurgeries,,painmanagementproceduresandradiationoncologyrequirePriorAuthorization.
PHARMACEUTICALPRODUCTS
PharmaceuticalProductsthatareadministeredonanoutpatientbasisinaHospital,AlternateFacility,
Practitioner’soffice,orinaCoveredPerson’shome.
BenefitsunderthissectionareprovidedonlyforPharmaceuticalProductswhich,duetotheir
characteristics(asdeterminedbyUs),musttypicallybeadministeredordirectlysupervisedbya
qualifiedPractitionerorlicensed/certifiedhealthprofessional.Benefitsunderthissectiondonot
includemedicationsthataretypicallyavailablebyprescriptionorderorrefillatapharmacy.
PODIATRYSERVICES
BenefitsforpodiatryservicesarelimitedtothefollowingCoveredServices:
• Treatmentofmedicalproblemsofthefeet,includingmedicalorsurgicaltreatmentrelatedto
disease,injury,ordefectsofthefeet;
• MedicallyNecessaryroutinefootcareforCoveredPersonswithcertainchronicconditionssuch
asDiabetes.
PREGNANCY—MATERNITYSERVICES
Benefitsforpregnancyincludeallmaternity-relatedmedicalservicesforprenatalcare,postnatalcare,
deliveryandanyrelatedcomplications.
BothbeforeandduringaPregnancy,Benefitsincludetheservicesofageneticcounselor,ifMedically
Necessary,whenprovidedorreferredbyaPractitioner.TheseBenefitsareavailabletoallCovered
Personsintheimmediatefamily.CoveredServicesincluderelatedtestsandtreatment. Prior
Authorizationisrequired.
CCHP17.EOC
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
CCHPwillpayBenefitsforanInpatientstayatthetimeofdeliveryofatleast:
• 48hoursforthemotherandnewbornchild(ifthechildisaddedtothePlan)followinga
vaginaldelivery;
• 96hoursforthemotherandnewbornchildfollowingacesareansectiondelivery.
Forcontinuityoftheircare,CoveredPersonsnewtothePlanaftertheirfirsttrimesterofpregnancymay
continuetoreceiveobstetriccarefromtheirOut-of-NetworkProviderthroughthecompletionof
postpartumcare.CoveredPersonsintheirfirstorsecondtrimester(startingatconceptionthrough25
completedweeksgestation)uponinitialenrollmentmusttransitiontoanIn-NetworkProvider. Prior
AuthorizationofanobstetricalservicereceivedatanOut-of-NetworkProviderisrequiredanddoesnot
extendtocarefortheinfant.
PREVENTIVECARESERVICES
BenefitsforpreventivecareservicesprovidedonanoutpatientbasisataPractitioner’sofficeoran
AlternateFacilityencompassmedicalservicesthathavebeendemonstratedbyclinicalevidencetobe
safeandeffectiveineithertheearlydetectionofdiseaseorinthepreventionofdisease,havebeen
proventohaveabeneficialeffectonhealthoutcomesandincludethefollowingasrequiredunder
applicablelaw:
• Evidence-baseditemsorservicesthathavearatingof"A"or"B"inthecurrent
recommendationsoftheUnitedStatesPreventiveServicesTaskForce.
• ImmunizationsthathavearecommendationfromtheAdvisoryCommitteeonImmunization
PracticesoftheCentersforDiseaseControlandPrevention.Thisincludesbutisnotlimitedto
Diphtheria,Pertussis,Tetanus,Polio,Measles,Mumps,Rubella,HemophilusinfluenzaB,
HepatitisB,andVaricella.
• Forinfants,childrenandadolescents,evidence-informedpreventivecareandscreenings
providedforinthecomprehensiveguidelinessupportedbytheHealthResourcesandServices
Administration.Thisincludesbloodleadtests.
• Forwomen,suchadditionalpreventivecareandscreeningsasprovidedforincomprehensive
guidelinessupportedbytheHealthResourcesandServicesAdministration.
• ForCoveredPersons,certaincancerscreeningsareconsideredpreventivecareservices,
includingcolorectalcancerscreenings.
CCHPcoverspreventivecareservicesasrequiredbytheAffordableCareActwithoutcharginga
deductible,coinsuranceorcopaymentwhentheseservicesareprovidedbyanIn-NetworkProviderina
primarysetting.CCHPcoverstheseservicesconsistentwiththerecommendationsandguidelinesofthe
UnitedStatesPreventiveServiceTaskForce(USPSTF)orotherregulatoryorganizationsbasedonage,
healthstatus,genderguidelines,andmedicalevidence.ConsultYourdoctorforYourspecificpreventive
healthrecommendations.
PelvicexamsandpapsmearsarecoveredunderthissectionwhendirectlyprovidedtoYoubya
physician,certifiednursemidwifeoranursepractitioner.
PreventivecareservicesmaynotbeperformedfortheprimaryreasonofdiagnosingortreatinganIllness
orInjury.
MoreinformationaboutthepreventiveservicescoveragerequiredundertheAffordableCareActcanbe
foundathttps://www.healthcare.gov/coverage/preventive-care-Benefits/.
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
PROSTHETICDEVICES
Externalprostheticdevicesthatreplacealimborabodypart,limitedto:
• Replacementofnaturalorartificiallimbsandeyes,earsandnosenolongerfunctionaldueto
physiologicalchangeormalfunctionbeyondrepair.
• IfmorethanoneprostheticdevicecanmeetYourfunctionalneeds,Benefitsareavailableonly
fortheprostheticdevicethatmeetstheminimumspecificationsforYourneeds.IfYoupurchase
aprostheticdevicethatexceedstheseminimumspecifications,Wewillpayonlytheamount
thatWewouldhavepaidfortheprostheticthatmeetstheminimumspecifications,andYouwill
beresponsibleforpayinganydifferenceincost.
• Theprostheticdevicemustbeorderedorprovidedby,orunderthedirectionofaPractitioner.
• BreastprosthesisasrequiredbytheWomen'sHealthandCancerRightsActof1998.Benefits
includemastectomybrasandlymphedemastockingsforthearm.
• Benefitsareavailableforrepairsandreplacement,exceptthat:
o TherearenoBenefitsforrepairsduetomisuse,maliciousdamageorgrossneglect.
o TherearenoBenefitsforreplacementduetomisuse,maliciousdamage,grossneglect
orforlostorstolenprostheticdevices.
Benefitsunderthissectionareprovidedonlyforexternalprostheticdevicesanddonotincludeany
devicethatisfullyimplantedintothebodyotherthanbreastprostheses.
CCHPwillcoverthepurchase,fitting,andnecessaryadjustmentstoprostheticswhentheyareMedically
Necessary. Repaircostswillbecoveredwhenthecostislessthan50%ofthecostofareplacement
item.Replacementcoveragemaybeprovidedwhenthecosttorepairthedamageditemexceeds50%
ofthepriceofanewitem;itisMedicallyNecessaryduetoachangeinYourmedicalcondition;repairof
theitemisnotafeasibleoption;ortheitemislostorstolenandYouprovideappropriate
documentationoftheeventsandcircumstancesoftheloss.Thedecisiontocoverrepairorreplacement
isatthesolediscretionofCCHP. PriorAuthorizationisrequiredforprostheticdevices.
RECONSTRUCTIVEPROCEDURES
BenefitsapplyonlyiftheinitialsurgerywasforthediagnosisortreatmentofaCoveredService.
ReconstructiveproceduresincludesurgeryorotherprocedureswhichareassociatedwithanInjury,
SicknessorCongenitalAnomaly.Theprimaryresultoftheprocedureisnotachangedorimproved
physicalappearance.
Benefitsforreconstructiveproceduresincludebreastreconstruction.SeethatsectionofCoveredServices
formoreinformation.
CosmeticServicesareexcludedfromcoverage.ProceduresthatcorrectananatomicalCongenital
AnomalywithoutimprovingorrestoringphysiologicfunctionareconsideredCosmeticServicesfactthat
aCoveredPersonmaysufferpsychologicalconsequencesorsociallyavoidantbehaviorasaresultofan
Injury,SicknessorCongenitalAnomalydoesnotclassifysurgery(orotherproceduresdonetorelieve
suchconsequencesorbehavior)asareconstructiveprocedure.
REHABILITATIVESERVICES
RehabilitativeServicesmustbeperformedbyaPractitionerorbyalicensedtherapyPractitioner.
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionand
PriorAuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
BenefitsunderthissectionincludeRehabilitativeServicesprovidedinaPractitioner’sofficeoronan
outpatientbasisataHospitalorAlternateFacility.Thecaremustbeforrestorationofafunctionor
abilitythatwaspresentandhasbeenlostduetobodilyinjuryorsickness.Therapymustbenecessitated
byamedicalconditionandnotbeprimarilyeducationalinnature.Benefitscanbedeniedorshortened
forCoveredPersonswhoarenotprogressingingoal-directedRehabilitativeServicesorifrehabilitation
goalshavepreviouslybeenmet.
BenefitsforRehabilitativeServicesinclude:
• PhysicalTherapy,20visitspercalendaryear.
• OccupationalTherapy,20visitspercalendaryear.Thisdoesnotincludeservicesasdescribed
underAutismSpectrumDisorderServices.
• SpeechTherapy,20visitspercalendaryear.Thisdoesnotincludeservicesasdescribedunder
AutismSpectrumDisorderServicesinthissection. PleasenotethatCCHPwillpayBenefitsfor
SpeechTherapyforthetreatmentofdisordersofspeech,language,voice,communicationand
auditoryprocessing.ForspeechtherapywithrelationtoAutismSpectrumDisorders,please
refertotheservicesdescribedunderAutismSpectrumDisorderServicesinthissection.
• ManipulativeTreatment. BenefitscanbedeniedorshortenedforCoveredPersonswhoarenot
progressingingoal-directedmanipulativetreatmentoriftreatmentgoalshavepreviouslybeen
met.Benefitsunderthissectionarenotavailableformaintenance/preventivemanipulative
treatment.
• CardiacRehabilitationTherapy,36sessionspercalendaryear.Cardiacrehabilitationis
coveredifthereisarecenthistoryof:
o Aheartattack.
o Coronary bypass surgery.
o Onset of angina pectoris.
o Heartvalvesurgery.
o Onsetofdecubitusangina.
o Percutaneoustransluminalcoronaryangioplasty(PTCA).
o Cardiactransplant.
• CognitiveRehabilitationTherapy,20sessionspercalendaryear.CCHPwillpayBenefitsfor
cognitiverehabilitationtherapyonlywhenMedicallyNecessaryfollowingapost-traumaticbrain
Injuryorcerebralvascularaccident(stroke).
• PulmonaryRehabilitation,20sessionspercalendaryear
• Post-cochlearimplantauraltherapy.
SKILLEDNURSINGFACILITY
ServicesandsuppliesprovidedinaSkilledNursingFacility.Benefitsarelimitedto30daysperstayand
requirePriorAuthorization.Benefitsareavailablefor:
• RoomandboardinaSemi-privateRoom(aroomwithtwoormorebeds).
• AncillaryServicesandsupplies—servicesreceivedduringtheInpatientstayincluding
prescriptiondrugs,diagnosticandtherapyservices.
PleasenotethatBenefitsareavailableonlyifbothofthefollowingaretrue:
• IftheinitialconfinementinaSkilledNursingFacilityorInpatientAcuteMedicalRehabilitation
FacilitywasorwillbeacosteffectivealternativetoanInpatientstayinaHospital.
• YouwillreceiveskilledcareservicesthatarenotprimarilyCustodialCare.
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
Skilledcareisskillednursing,skilledteachingandskilledRehabilitativeServiceswhenallofthefollowing
aretrue:
• Itmustbedeliveredorsupervisedbylicensedtechnicalorprofessionalmedicalpersonnelin
ordertoobtainthespecifiedmedicaloutcome,andprovideforthesafetyofthepatient.
• ItisorderedbyaPractitioner.
• Itisnotdeliveredexclusivelyforthepurposeofassistingwithactivitiesofdailyliving,including
dressing,feeding,bathingortransferringfromabedtoachair.
• Itrequiresclinicaltraininginordertobedeliveredsafelyandeffectively.
WewilldetermineifBenefitsareavailablebyreviewingboththeskillednatureoftheserviceandthe
needforPractitioner-directedmedicalmanagement.Aservicewillnotbedeterminedtobeskilled
simplybecausethereisnotanavailablecaregiver.
BenefitscanbedeniedordiscontinuedforCoveredPersonswhoarenotprogressingingoal-directed
RehabilitativeServicesorifdischargerehabilitationgoalshavepreviouslybeenmet.
SkillednursingservicesmustbeprovidedwiththeexpectationthatYouhavethepotentialtobe
restoredinareasonableandgenerallypredictableperiodoftimeandwillcontinuetomakesubstantial
improvementinYourleveloffunctioning.OnceYoureachamaintenanceleveland/ornofurther
progressisbeingattained,thecareandservicesprovidedwillnolongerbeconsidered“skillednursing.”
Theserviceswillinsteadbeconsideredcustodialcare.
TEMPOROMANDIBULARJOINTDISORDERSERVICES
Diagnosticproceduresandsurgicalornon-surgicaltreatment(includingprescribedintraoralsplint
therapydevices)forthecorrectionoftemporomandibularjointdisorders(TMJ)andassociatedmuscles,
ifallofthefollowingapply:
• Theconditioniscausedbycongenital,developmentaloracquireddeformity,diseaseorInjury.
• Thereisclearlydemonstratedradiographicevidenceofsignificantjointabnormality.
• Theprocedureordeviceisreasonableandappropriateforthediagnosisortreatmentofthe
condition.
• Thepurposeoftheprocedureordeviceistocontroloreliminateinfection,pain,diseaseor
dysfunction.
• Benefitsarenotavailableforcosmeticorelectiveorthodonticcare,periodonticcareorgeneral
dentalcare.
Benefitsforsurgicalservicesincludearthrocentesis,arthroscopy,arthroplasty,arthrotomyandopenor
closedreductionofdislocations.Non-surgicaltreatmentincludesclinicalexaminations,oralappliances
(orthoticsplints),arthrocentesisandtrigger-pointinjections.
ORGANANDTISSUETRANSPLANTSERVICES
CCHPwillcoverorganandtissuetransplantservicesifthefollowingcriteriaaremet:
• TheCoveredPerson’sPractitionerandWemustapprove,inwriting,thecoveredorganorDNA
tissuetransplantandrelatedservices;
• TheCoveredPerson’sconditionmustmeetthecriteriaofandbeapprovedbyCCHP’s
DesignatedTransplantProviderandUs;
• Thespecifictypeoftransplantmustbeeffectivetherapyforthecondition.Expertmedical
professionalsataCCHPapprovedtransplantcenterwillmakethisdeterminationforUs;
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
•
•
•
•
Thepotentialbenefitofthetransplantmustoutweighthepotentialrisk;
Thespecifictypeoftransplantmustprovidemorebenefitthanothertherapies,giventhe
CoveredPerson’smedicalcondition;
ThespecifictypeoftransplantmustimprovetheCoveredPerson’squalityoflifeandhealthor
functionalstatus.Todeterminethis,CCHPwillrelyonlyonscientificallydesignedandcontrolled
researchstudies.CCHPwillrelyonlyonsuchstudiespublishedinpeerreviewedmedical
publicationsthatareacceptedasappropriatebythetransplantoroncologyacademic
communities;
TheCoveredPersonmustnothaveaterminaldiseasethatthetransplantwouldnotcorrector
cure.
CCHPwillapprovetransplantsthatmeetthefollowingcriteria:
• Haveavailablefortransplantappropriatedonororgans,bonemarroworstemcells;
• AnapprovedDesignatedTransplantProvidermustfurnishthecare;
• ArenotExperimentalorInvestigationalTreatment,orforresearchpurposes;and
• CaremustbeprovidedinfullcompliancewiththisContract.CCHPcoversthefollowingorgan
andtissuetransplantservices,subjecttotherestrictionsdescribedabove.
• Medical,surgical,andHospitalservicesandcostsrelatedtoobtainingorgans.Thisincludes
servicesrequiredtoperformthefollowinghumanorganortissuetransplants.
• CCHPwillcoversuchservicesonlyifPriorAuthorizationisreceived.WewillbasePrior
AuthorizationonindicationsandcriteriaforMedicalNecessity.
Benefitsareprovidedforthefollowingtransplantsandrelatedcosts:
• Heart;
• Liver;
• Liver/Smallbowel;
• Pancreas;
• BoneMarrow(AutologousselftoselforAllogenicothertoself);
• Kidney;
• Heart/Lung;
• Singlelung;
• Bilateralsequentiallung;
• Corneal(PriorAuthorizationnotrequired);
• Kidney/Pancreas;
• Intestinal;
• Re-transplantationforthetreatmentoforganfailureorrejection.
• Immunosuppressiveoranti-rejectionmedications.Thesedrugsmustbeforanapproved
transplant.Costsharingmayapply,asdescribedintheScheduledofBenefits.
• DonorcoststhataredirectlyrelatedtoorganremovalareCoveredServicesforwhichBenefits
arepayablethroughtheorganrecipient’scoverageunderthisContract.
URGENTCARE
WithintheServiceArea,CCHPwillonlycoverUrgentCarefurnishedbyanIn-Network-Provideroratan
UrgentCareFacility.
OutsideoftheServiceArea,CCHPwillcoverUrgentCarewhenreceivedatanUrgentCareFacility.Any
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
requiredfollow-upcaremustbefurnishedbyanIn-NetworkProvider.
CCHPwillnotpayforUrgentCareservicesreceivedfortheCoveredPerson’sconvenience.
RefertoEmergencyHealthServices–Outpatientforadditionaldetails.
URINARYCATHETERS(INTERMITTENTANDINDWELLING)
BenefitsforintermittentandindwellingurinarycathetersareforCoveredPersonswhohavepermanent
urinaryincontinenceorpermanenturinaryretention.Permanenturinaryretentionisdefinedas
retentionthatisnotexpectedtobemedicallyorsurgicallycorrectedinthatpersonwithin3months.
Coveredsupplieswithquantities:
• Lubricant,individualsterilepack,each–150permonth.
• Intermittenturinarycatheter;straighttip,withorwithoutcoating(teflon,silicone,silicone
elastomer,orhydrophilic,etc.),each–150permonth.
• Intermittenturinarycatheter;coude(curved)tip,withorwithoutcoating(Teflon,silicone,
siliconeelastomeric,orhydrophilic,etc.),each–150permonth.
• Intermittenturinarycatheter,withinsertionsupplies-150permonth.
• Insertiontraywithdrainagebagwithindwellingcatheter,Foley-type,2-way,latexwithcoating–
1permonth.
• Insertiontraywithdrainagebagwithindwellingcatheter,Foley-type,2-way,allsilicone–1per
month.
• Insertiontraywithdrainagebagwithindwellingcatheter,Foley-type,3-way,forcontinuous
irrigation–1permonth.
• Insertiontraywithdrainagebagbutwithoutcatheter–1permonth.
• Bedsidedrainagebag,dayornight,withorwithoutanti-refluxdevice,withorwithouttube,
each-2permonth.
• Urinarylegbag;latex-1permonth.
VISIONCARESERVICES-PEDIATRIC
CCHPoritsdesigneewillcoverroutineeyeexamsandhardwareforchildrenuptoage19.Theexam
mayscreenforeyedisordersandassesstheneedforprescriptioncorrectiveorcontactlenses.CCHPor
itsdesigneewillonlypayforservicesanIn-NetworkProviderfurnishes. PleasecontactOurEyewear
BenefitManagerforalistofIn-NetworkProviders.
CCHPwillcoveroneroutineeyeexamwhichincludesthedeterminationoftherefractivestate/dilation
whenprofessionallyindicatedandlenses(glassesorcontacts)foreacheligibleCoveredPersonper
benefityear,andonepairofeyeglassframeseverytwoyears.
Lenses:
• Singlevision,linedbifocal,linedtrifocalorlenticularlensescoveredinfull.
• Polycarbonatelensescoveredinfull.
• Plasticorglassoptionalcoveredinfull.
• ScratchandUVcoveredinfull.
Frames:
• FramesfromaPediatricEyewearCollectionarecoveredinfulleverytwoyears.
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CoveredHealthServices
COVEREDHEALTHSERVICES WeprovideBenefitsforthefollowingMedicallyNecessaryCoveredServices.PleaseseetheExclusionandPrior
AuthorizationsectionsforlimitationstoCoveredServices. ContactCustomerServicewithanyquestions.
ContactLenses:Inlieuofeyeglasses,electivecontactlensesarecoveredinfullwiththefollowing
servicelimitations:
• Standard(onepairannually)=Onecontactlenspereye(total2lenses).
• Monthly(six-monthsupply)=Sixlensespereye(total12lenses).
• Bi-weekly(three-monthsupply)=Sixlensespereye(total12lenses).
• Dailies(one-monthsupply)=30lensespereye(total60lenses).
MedicallyNecessarycontactlensesarecoveredinfullforCoveredPersonswhohavespecificocular
conditionswhereMedicallyNecessarycontactlensesprovidebettervisualcorrectionthanspectacleeye
wear.
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CoveredHealthServices
PRIORAUTHORIZATION
Children’sCommunityHealthPlan(CCHP)wantsOurmemberstogetthebestpossiblecarewhenthey
needitmost.Toensurethis,WeuseaPriorAuthorizationprocess,whichispartofOurUtilization
Management(UM)program.UMdecision-makingisbasedonlyonappropriatenessofcareandservice,
availableforthosememberswhohaveactivecoverage.CCHPdoesnotrewardpractitionersorother
individualsforissuingdenialsofcoverage.FinancialincentivesforUMdecisionmakersdonotencourage
decisionsthatresultinunderutilizationordenialsofcoverage.
CCHPcontractedPractitionersareresponsibleforobtainingPriorAuthorizationbeforetheyprovide
servicestoYou.However,ifaPractitionerisnotcontractedwithCCHPandprovidesservicesorif
YourPractitionerdoesnotcontactUs,itisultimatelyYourresponsibilitytoensurePrior
Authorizationwasobtained.TheCoveredServicesforwhichWerequirePriorAuthorizationarelisted
below,andintheScheduleofBenefitstable.
BeforereceivingCoveredServicesfromwhatappearstobeaCCHPPractitioner,Youmaywanttocontact
CCHPtoverifythatthehospitalorPractitionerisanIn-NetworkProvider. ThereisNOcoverageavailable
ifdonotgotoaCCHPPractitioner,unlessPriorAuthorizationisreceivedorunlessitisanEmergency.
InsomesituationsYoumayneedmedicalattentionbeforethePriorAuthorizationprocesscantake
place.PleasenotethatinurgentorEmergencyhospitalInpatientadmissions,thoughPriorAuthorization
isnotrequired,CCHPmustbenotifiedwithin24hoursoftheInpatientadmission.
PriorAuthorizationdoesnotguaranteeeitherpaymentofbenefitsortheamountofbenefits.Eligibility
for,andpaymentofbenefitsaresubjecttoalltermsandconditionsofthisContract.IfYouchooseto
receiveaservicethathasbeendeterminednottobeMedicallyNecessary,isnotaCoveredService,or
hasnotbeenPriorAuthorizedthoughPriorAuthorizationisrequired,Youwillberesponsibleforpaying
allchargesandnoBenefitswillbepaid.
IfYourPractitionerbelievesthatadditionalcarebeyondtheservicesspecified,orthelengthoftime
originallyauthorized,isMedicallyNecessary,CCHPmustbecontactedtorequestanextensionofthe
originalPriorAuthorization.YouandYourPractitionerwillbenotifiedwhethertherequestforan
extensionisapprovedordenied.
PROCESSFOROBTAININGPRIORAUTHORIZATION
YoushouldaskyourhealthcarePractitionertostartthePriorAuthorizationprocessassoonaspossible
beforethebeginningoftreatment.YourPractitionercansubmitaPriorAuthorizationrequestonline
throughtheCCHPProviderPortal[https://provider.childrenscommunityhealthplan.org/Provider-Portal].
YouorYourPractitionercancontactCustomerServicewithquestionsonthePriorAuthorizationprocess.
URGENTPRE-SERVICEREQUESTS
IfYouorahealthcareprofessionalwithknowledgeofYourmedicalconditionhaveanurgentrequestfor
PriorAuthorization,YoumaysubmittherequesttoUsviatheCCHPProviderPortal.Wewillmakea
decisiononYourrequestandnotifyyouwithin72hoursofOurreceiptofacorrectlysubmitted
request,orassoonaspossibleifYourconditionrequiresashortertimeframe.
AnurgentrequestisanyrequestforPriorAuthorizationformedicalcareortreatmentwithrespectto
whichtheapplicationofthetimeperiodsformakingnon-urgentcaredeterminationscouldseriously
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PriorAuthorization
PRIORAUTHORIZATION
jeopardizethelifeorhealthoftheCoveredPersonortheabilityoftheCoveredPersontoregain
maximumfunctionorintheopinionofaphysicianwithactualknowledgeoftheCoveredPerson’s
medicalcondition,wouldsubjecttheCoveredPersontoseverepainthatcannotbeadequatelymanaged
withoutthecareortreatmentthatisbeingrequested.
IfYourrequestisincompleteorincorrectlyfiled,WewillnotifyYouofthespecificinformationWeneed
assoonaspossible,butnolaterthan24hoursafterWereceiveYoururgentrequest. Youwillthenhave
48hoursfromthereceiptofthenoticetoprovideUswiththerequestedinformation. Within48hours
ofOurreceiptoftheadditionalinformation,WewillgiveOurdecisionontheurgentrequest.IfYoufail
toprovidetheinformationrequestedbyUs,WewillprovideYouwithOurdecisionbasedonthecurrent
informationthatWehavewithin48hoursoftheendoftheperiodthatYouweregiventoprovidethe
information.
IfYoufailtofollowOurprocedureforPriorAuthorizationrequests,WewillnotifyYouwithin24hoursof
Ourreceiptoftherequest. Thenoticewillincludethereasonwhytherequestfailedandtheproper
processforobtainingpriorapprovalorprecertification.
NON-URGENTPRIORAUTHORIZATIONREQUESTS
WewillmakeadecisiononYournon-urgentrequestswithin15daysofOurreceiptofacorrectly
submittedrequest.Iftherequestisanincompletepriorauthorizationorincorrectlyfiledprior
authorization,WewillnotifyYouofa15dayextensionandthespecificinformationneeded.Youwill
thenhave45daysfromthereceiptofthenoticetoprovidetherequestedinformation.OnceWehave
receivedtheadditionalinformation,WewillmakeOurdecisionwithintheperiodoftimeequaltothe
15-dayextensioninadditiontothenumberofdaysremainingfromtheinitial15-dayperiod.For
example,ifOurnotificationwassenttoYouonthefifthdayofthefirst15-dayperiod,Wewouldhavea
totalof25daystomakeadecisiononYourpriorauthorizationfollowingthereceiptoftheadditional
information.UndernocircumstanceswilltheperiodformakingafinaldeterminationonYourprior
authorizationexceed75daysfromthedateWereceivedthenon-urgentpre-serviceclaim.IfYoufailto
followOurprocedureforPriorAuthorizationrequests,WewillnotifyYouwithinfivedaysofourreceipt
oftherequest.Thenoticewillincludethereasonwhytherequestfailedandtheproperprocessfor
obtainingPriorAuthorization.
REQUESTSFOREXTENSIONS
IfYourPractitionerbelievesthatadditionalcarebeyondtheservicesspecified,orthelengthoftime
originallyauthorized,isMedicallyNecessary,CCHPmustbecontactedtorequestanextensionofthe
originalPriorAuthorization.YouandYourPractitionerwillbenotifiedwhethertherequestforan
extensionisapprovedordenied.
COVEREDSERVICESWHICHREQUIREPRIORAUTHORIZATION
Ambulance-nonemergencyairandground
Anyprocedurethatcouldbeconsideredcosmetic,including:
BreastReductionandMastectomyforGynecomastia
AutismSpectrumDisorderservices
Bone-anchoredhearingdevice
CochlearImplants
Dental/anesthesiaandfacilityservicefordentalservices
Dialysis
DurableMedicalEquipment(DME):CCHPwilldecideiftheequipmentshouldbepurchasedor
rented. PriorAuthorizationisrequiredforaretailpurchaseprice$500orgreaterforasingle
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PriorAuthorization
PRIORAUTHORIZATION
itemwhetherapurchasepriceoramonthlyrentalprice.
EEG,VideoMonitoring
ElectiveSurgeriesincluding:
o KneeArthroplasty,Total
o ElbowArthroplasty
o ShoulderArthroplasty
o ShoulderHemiarthroplasty
o HipArthroplasty
o Hysterectomy
o WristArthroplsty
o Cervicalandlumbarlaminectomy,diskectomy/microdiskectomy
o SympathectomybyThoracoscopyorLaparoscopy
o UrethralSuspensionProcedures
o ElectrophysiologicStudyandImplantableCardioverter-Defibrillator(ICD)Insertion,Transvenous
GeneticTesting,includingBRCAgenetictesting
Homehealthcare
HospiceCare
InpatientHospitalstaysrequirenotificationwithin24hoursofadmission
InpatientRehabilitation
MentalHealthServices,includingthefollowinglevelsofcare:
o Inpatientstaysrequirenotificationwithin24hoursofadmission
o Partialhospitalization
o Daytreatment
o Intensiveoutpatient
PETscans
ProstheticDevices
ProtonBeamTherapy(PBT)
PainManagementprocedures(includingbutnotlimitedto:epiduralsteroidinjectionsandradio
frequencyablationandspinalcordstimulators
RadiationOncology
Reconstructiveprocedures,excludingbreastreconstructionsurgeryfollowingmastectomy
SkilledNursingFacility
SpecialtyMedications
SubstanceUseDisorderServices,includingthefollowinglevelsofcare:
o Inpatient
o Partialhospitalization
o Daytreatment
o Intensiveoutpatient
Transplants
*Maybesubjecttoexceptions.ContactCCHPCustomerServicetofindoutifYourserviceneedsPrior
Authorization.
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PriorAuthorization
EXCLUSIONSANDLIMITATIONS
NotallhealthcareservicesareCoveredServices.Thefollowingisalistofservicesthatarenotcovered.
ALTERNATIVETREATMENTS
• Acupressureandacupuncture.
• Aromatherapy.
• Arttherapy,musictherapy,dancetherapy,horsebacktherapyandotherformsofalternative
treatmentasdefinedbytheNationalCenterforComplementaryandAlternativeMedicine
(NCCAM)oftheNationalInstitutesofHealth.
• Ayurvedicmedicine.
• BESTorAITtherapy.
• Colonicirrigation.
• Contactreflexanalysis.
• Dietaryproducts.
• Electromagnetictherapy.
• Guidedimagery.
• Herbalmedicine/therapy.
• Homeopathy.
• Holisticmedicine.
• Hypnosis/hypnotism(ClinicalHypnotherapyiscoveredifofferedaspartofacourseof
behavioralcounseling/therapybyanaccreditedprofessional).
• Iridology.
• Magneticinnervationtherapy.
• Massagetherapy.
• Naturopathy.
• Neurofeedback.
• Orthomoleculartherapy.
• Reiketherapy.
• Relaxationtherapy.
• Rolfing.
• Swimorpooltherapy.
• TherapeuticTouch.
• Thermography.
• Transcendentalmeditation.
• Yoga.
ASSISTEDFERTILZATION
Assistedfertilizationservices,including,butnotlimitedto,GIFT,ZIFT,embryotransplants,intrauterine
insemination,andinvitrofertilization.
AUTISMSPECTRUMDISORDERSERVICES
ExclusionslisteddirectlybelowapplytoservicesdescribedunderAutismSpectrumDisorderservicesin
CoveredServicessection. Thisisnotanall-inclusivelist.
AutismSpectrumDisorderservicesnotcoveredinclude:
• Acupuncture.
• Animal-basedtherapyincludinghippotherapy.
• Auditoryintegrationtraining.
CCHP17.EOC
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Exclusions
EXCLUSIONSANDLIMITATIONS
NotallhealthcareservicesareCoveredServices.Thefollowingisalistofservicesthatarenotcovered.
•
•
•
•
•
•
Chelationtherapy.
Childcarefees.
Cranialsacraltherapy.
Custodialorrespitecare.
Hyperbaricoxygentherapy.
Specialdietsorsupplements.
BARIATRICSURGERY
BariatricSurgerywhetheroriginalprocedureorrevisionsisnotcoveredunderanycircumstances.
BLOOD
Non-purchasedbloodorbloodproducts,includingautologousdonations.
COSMETICSURGERYANDSERVICES
Surgical,prescriptiondrugsorotherservicesforcosmeticpurposesperformedtorepairorreshapea
bodystructurefortheimprovementoftheperson’sappearanceorforpsychologicaloremotional
reasons,andfromwhichnoimprovementinphysiologicalfunctioncanbeexpected,exceptassuch
surgeryorservicesarerequiredtobecoveredbylaw.Excludedservicesinclude,butarenotlimitedto,
portwinestains,augmentationprocedures,reductionprocedures,andscarrevisions.
COURTORDERED
Court-orderedserviceswhenYourPractitionerorotherprofessionalPractitionerdeterminesthat
thoseservicesarenotMedicallyNecessary.
CUSTODIALCARE
CustodialCare,domiciliarycare,orprotectiveandsupportivecare,including,butnotlimitedto,respite
care,educationalservices,convalescentcare,dietaryservices,homemakerservices,maintenance
therapy,andfoodorhome-deliveredmeals.
DENTALSERVICESNOTPROVIDEDINTHISPOLICY
CCHPwillnotcoverroutinedentalcareorservicesbeyondwhatislistedinthisContract,includingthe
following:
• Dentalcare(whichincludesdentalX-rays,suppliesandappliancesandallassociatedexpenses,
includinghospitalizationsandanesthesia).
o Thisexclusiondoesnotapplytoaccident-relateddentalservicesforwhichBenefitsare
providedasdescribedunderDentalServices–AccidentOnlyandDental/Anesthesia
ServicesandTemporomandibularJointDisorderServicesintheCoveredServices
section.
o Thisexclusiondoesnotapplytodentalcare(oralexamination,X-rays,extractionsand
non-surgicaleliminationoforalinfection)requiredforthedirecttreatmentofamedical
conditionforwhichBenefitsareavailableunderthisContract,limitedto:
§ Transplantpreparation.
§ Priortotheinitiationofimmunosuppressivedrugs.
Priortoasplenectomy.
§ ThedirecttreatmentofacutetraumaticInjury,cancerorcleftpalate.
• Dentalcarethatisrequiredtotreattheeffectsofamedicalcondition,butthatisnotnecessary
todirectlytreatthemedicalcondition,isexcluded.Examplesincludetreatmentofdentalcaries
resultingfromdrymouthafterradiationtreatmentorasaresultofmedication.
CCHP17.EOC
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Exclusions
EXCLUSIONSANDLIMITATIONS
NotallhealthcareservicesareCoveredServices.Thefollowingisalistofservicesthatarenotcovered.
•
•
•
•
•
Endodontics,periodontalsurgeryandrestorativetreatmentareexcluded.
Preventivecare,diagnosis,treatmentoforrelatedtotheteeth,jawbonesorgums.Examples
includeextraction,restorationandreplacementofteeth,medicalorsurgicaltreatmentsof
dentalconditionsandservicestoimprovedentalclinicaloutcomes.
o Thisexclusiondoesnotapplytoaccident-relateddentalservicesforwhichBenefitsare
providedasdescribedunderDentalServices–AccidentOnlyandDental/Anesthesia
Services-HospitalorAmbulatorySurgeryServicesandTemporomandibularJoint
DisorderServicesintheCoveredServicessection.
Dentalimplants,bonegraftsandotherimplant-relatedprocedures.Thisexclusiondoesnot
applytoaccident-relateddentalservicesforwhichBenefitsareprovidedasdescribedunder
DentalServices–AccidentOnlyandDental/AnesthesiaServices-HospitalorAmbulatory
SurgeryServicesandTemporomandibularJointDisorderServicesintheCoveredServices
section.
Dentalbraces(orthodontics).
Treatmentofcongenitallymissing,mal-positionedorsupernumeraryteeth,evenifpartofa
CongenitalAnomaly.
DEVICES,APPLIANCESANDPROSTHETICS
• Devicesusedspecificallyassafetyitemsincludingcarseatsorboosterseatsortoaffect
performanceinsports-relatedactivities.
• Orthoticappliancesthatstraightenorre-shapeabodypart.Examplesincludefootorthoticsand
sometypesofbraces,includingover-the-counterorthoticbraces. Theseexclusionsdonotapply
forCoveredPersonswhoareatriskofneurologicalorvasculardiseasearisingfromdiseases
suchasDiabetes.
• Thefollowingitemsareexcluded,evenifprescribedbyaPractitioner:
o Bloodpressurecuff/monitor.
o Enuresisalarm.
o Non-wearableexternaldefibrillator.
o Trusses.
• Devicesandcomputerstoassistincommunicationandspeechexceptforspeechaiddevices
andtracheo-esophagealvoicedevicesforwhichBenefitsareprovidedasdescribedunder
DurableMedicalEquipmentintheCoveredServicessection.
• CorrectiveAppliancesprimarilyintendedforathleticpurposesorrelatedtoasportsmedicine
treatmentplan,andotherappliances/devices,andanyrelatedservices,including,butnotlimited
to,children’scorrectiveshoes,archsupports,specialclothingorbandagesofanytype,back
braces,lumbarcorsets,handsplints,kneebraces,andshoeinsertsandorthopedicsshoesexcept
asdescribedintheProstheticDevicesintheCoveredServicessection.
• Oralappliancesforsnoring.
• Repairstoprostheticdevicesduetomisuse,maliciousdamageorgrossneglect.
• Replacementofprostheticdevicesduetomisuse,maliciousdamageorgrossneglectorto
replacelostorstolenitems.
• Wearableroboticexoskeletonsystems.
EMPLOYMENT-RELEATEDOREMPLOYER-SPONSORED
Foranyillnessorbodilyinjurythatoccursinthecourseofemployment,ifBenefitsorcompensationis
availableinwholeorinpart,pursuanttoanyfederal,state,orlocalgovernment’sworkers’
compensation,oroccupationaldisease,orsimilartypeoflegislation.Thisexclusionapplieswhetheror
CCHP17.EOC
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Exclusions
EXCLUSIONSANDLIMITATIONS
NotallhealthcareservicesareCoveredServices.Thefollowingisalistofservicesthatarenotcovered.
notYouclaimthoseBenefitsorcompensation.ServicesthatYoureceivefromadentalormedical
department,operatedinwholeorinpartby,oronbehalfof,anemployer,mutualbenefitassociation,
laborunion,trust,orsimilarentity.
ENGAGEDINANILLEGALACTOROCCUPATION
Foranycare,treatment,orservice,includingcoverageofprescriptiondrugsrequiredasaresultofany
losssustainedorcontractedinconsequenceofYourbeingengagedinanillegalactoroccupation.
EXPERIMENTAL/INVESTIGATIONAL
ServicesorprescriptiondrugsthatareExperimentalorInvestigationalTreatmentasdeterminedby
CCHP.
FOODSUPPLEMENTS/VITAMINS
Food,foodsupplements,vitamins,andothernutritionalandover-the-counterelectrolytesupplements,
exceptasotherwisereferencedintheCoveredServicessection.
FOOTCARE
• Routinefootcare.Examplesincludethecuttingorremovalofcornsandcalluseshypertrophyor
hyperplasiaoftheskinorsubcutaneoustissuesofthefeet.
• Nailtrimming,cutting,ordebriding.
• Hygienicandpreventivemaintenancefootcare.Examplesinclude:
o Cleaningandsoakingthefeet.
o Applyingskincreamsinordertomaintainskintone.
• Treatmentofflatfeet.
• Treatmentofsupinationorpronationofthefoot.
• Shoes.
• Shoeorthotics.
• Shoeinserts.
• Archsupports.
TheseexclusionsdonotapplytopreventivefootcareforCoveredPersonswhoareatriskofneurological
orvasculardiseasearisingfromdiseasessuchasDiabetes.
GENETICCOUNSELINGANDTESTING
GeneticcounselingandtestingnotMedicallyNecessaryfortreatmentofadefinedmedicalcondition,
exceptwhensuchcoverageisrequiredbytheAffordableCareAct.
GROWTHHORMONES
GrowthhormonetherapyunlessprescribedforClassicGrowthHormoneDeficiency,Turner’ssyndrome,
orcertainotherdiagnosesasdeterminedbyCCHPandauthorizedinaccordancewithapplicablepolicy
andprocedure.
HABILITATIVESERVICES
ServicesanddiagnosesnotspecificallylistedintheCoveredServicessection,includingbutnotlimitedto
respitecare,daycare,recreationalcare,residentialtreatment,socialservices,custodialcare,or
educationservicesofanykind.
CCHP17.EOC
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Exclusions
EXCLUSIONSANDLIMITATIONS
NotallhealthcareservicesareCoveredServices.Thefollowingisalistofservicesthatarenotcovered.
HOMECARE
Homecareforchronicconditionssuchaspermanent,irreversibledisease,injuries,orcongenital
conditions.
EMPLOYMENT,SCHOOLANDTRAVELRELATEDSERVICES
Physicalexaminations,immunizations,testing,servicesanddrugsrequiredforforeigntravel,school,
sportsoremployment,unlesscoverageisrequiredbytheAffordableCareAct.
MAINTENANCETHERAPY
CoverageforRehabilitativeServiceswillceasewhenmeasurableandsignificantprogresstoward
expectedandreasonableoutcomeshasbeenachievedorhasplateauedasdeterminedbyUs.
MATERNITYSERVICES
• Electiveabortionsaretobeexcluded,exceptwhenperformedtosavethelifeofthemother,or
ifthepregnancyistheresultofrapeorincest,consistentwithstateandfederallaws.
• Homeorintendedoutofhospitaldeliveries.
• Ultrasound,Amniocentesisand/orCVS(ChorionicVilliSampling)performedexclusivelyforsex
determination.
• Birthingclasses.
• Treatment,services,orsuppliesforathirdpartyornonmembertraditionalsurrogateor
gestationalcarrier.
MEDICALSERVICESNOTPROVIDEDINTHISCONTRACT
Anyothermedicalserviceortreatment,exceptasprovidedintheCoveredServicessectionofthis
Contract,orasmandatedbylaw.
MEDICALSUPPLIES
Non-prescribedmedicalsupplies,whichincludebutarenotlimitedto:
• Compressionstockingsand/orelasticstockings.
• Acebandages.
• Gauzeanddressings.
MEDICALLYUNNECESSARYSERVICES
ServicesthatarenotMedicallyNecessaryasdeterminedbyCCHP.
MENTALHEALTHANDSUBSTANCEUSEDISORDERSERVICES
Thefollowingbehavioralhealthservices(unlessprovidedelsewhereinthisContract):
• Servicesperformedinconnectionwithconditionsnotclassifiedinthecurrenteditionofthe
DiagnosticandStatisticalManualofMentalDisorders(DSM).
• Servicesthatextendbeyondtheperiodnecessaryforevaluation,diagnosis,theapplicationof
evidence-basedtreatmentsorcrisisinterventiontobeeffective.
• Services as treatment for a primary diagnosis of insomnia and other sleep disorders, sexual
dysfunction disorders, feeding disorders, neurological disorders and other disorders with a
knownphysicalbasis.
• Treatmentsfortheprimarydiagnosesoflearningdisabilities,conductandimpulsecontrol
disorders,personalitydisordersandparaphilias,andotherMentalHealthDisordersthatwillnot
substantiallyimprovebeyondthecurrentleveloffunctioning,orthatarenotsubjectto
favorablemodificationormanagementaccordingtoprevailingnationalstandardsofclinical
CCHP17.EOC
57
Exclusions
EXCLUSIONSANDLIMITATIONS
NotallhealthcareservicesareCoveredServices.Thefollowingisalistofservicesthatarenotcovered.
practices,asreasonablydeterminedbythePractitioner.ThisexclusiondoesnotapplyforMental
HealthDisorderservicesprovidedastheresultofanEmergencydetention,commitmentorcourt
order.
• Educational/behavioralservicesthatarefocusedonprimarilybuildingskillsandcapabilitiesin
communication,socialinteractionandlearning.
• Tuitionfororservicesthatareschool-basedforchildrenandadolescentsundertheIndividuals
withDisabilitiesEducationAct.
• Learning,motorskillsandprimarycommunicationdisordersasdefinedinthecurrentedition
oftheDiagnosticandStatisticalManualoftheAmericanPsychiatricAssociation.
• MentalretardationwithAutismSpectrumDisorderasaprimarydiagnosisdefinedinthe
currenteditionoftheDiagnosticandStatisticalManualoftheAmericanPsychiatric
Association.BenefitsforAutismSpectrumDisorderasaprimarydiagnosisaredescribed
underAutismSpectrumDisorderServicesinCoveredServices.
• Treatmentprovidedinconnectionwithortocomplywithinvoluntarycommitments,police
detentionsandothersimilararrangements,unlessauthorizedbythePractitioner.Ifservicesfora
nervousorMentalHealthDisorderoccurasaresultofanEmergencydetention,commitmentor
courtorder,theserviceswillbecovered.
• ServicesorsuppliesforthediagnosisortreatmentofaMentalHealthDisorderthat,inthe
reasonablejudgmentofthePractitioner,areanyofthefollowing:
o Notconsistentwithgenerallyacceptedstandardsofmedicalpracticeforthe
treatmentofsuchconditions.
o Notconsistentwithservicesbackedbycredibleresearchsoundlydemonstrating
thattheservicesorsupplieswillhaveameasurableandbeneficialhealthoutcome,
andthereforeconsideredexperimental.
o Typicallydonotresultinoutcomesdemonstrablybetterthanotheravailable
treatmentalternativesthatarelessintensiveormorecosteffective.
o NotconsistentwiththePractitioner’slevelofcareguidelinesorbestpracticesas
modifiedannually.
o Notclinicallyappropriateintermsoftype,frequency,extent,siteanddurationof
treatment,andconsideredineffectiveforthepatient'sMentalHealthDisorder,
SubstanceUseDisorderorconditionbasedongenerallyacceptedstandardsof
medicalpracticeandbenchmarks
• Treatmentandservicesreceivedataresidentialtreatmentcenter.
MILITARYSERVICE
Careformilitaryservice-connecteddisabilitiesandconditionsforwhichYouarelegallyentitledto
servicesandforwhichfacilitiesarereasonablyaccessibletoYou.Servicesthatareprovidedtomembers
ofthearmedforcesortoindividualsinVeteransAdministrationfacilitiesformilitaryservicerelated
IllnessorInjury,unlessYouhavealegalobligationtopay.
MISCELLANEOUS
Anyservices,supplies,ortreatmentsnotspecificallylistedinthisContract,unlesstheyare
preventivecareservices.
• ServicesandsupplieswhicharenotprovidedorarrangedbyaPractitionerandauthorizedfor
paymentinaccordancewithCCHP’smedicalmanagementpoliciesandprocess.
• Anyservicesrelatedtoornecessitatedbyanexcludeditemornon-CoveredService.
• Servicesprovidedbyanon-licensedpractitioner.
CCHP17.EOC
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Exclusions
EXCLUSIONSANDLIMITATIONS
NotallhealthcareservicesareCoveredServices.Thefollowingisalistofservicesthatarenotcovered.
•
•
•
•
•
•
•
•
•
Servicesthatareprimarilyeducationalinnature,including,butnotlimitedto,vocational
rehabilitationorrecreationaloreducationaltherapy.
ServicesrenderedpriortotheeffectivedateofYourcoverageorincurredafterthedateof
terminationofYourcoverage,exceptasprovidedelsewhereinthisContract.
ServicesforwhichYouotherwisewouldhavenolegalobligationtopay.
Chargesforfailuretokeepascheduledappointment.
ServicesperformedbyaprofessionalPractitionerenrolledinaneducationortraining
programwhensuchservicesarerelatedtotheeducationortrainingprogram.
Chargesforcompletionofanyinsuranceformorcopyingofmedicalrecords.
ServicesrenderedbyaprofessionalPractitionerwhoisamemberofYourimmediatefamily.
ImmediatefamilyisdefinedasYourspouse,child,stepchild,parent,sibling,son-in-law,
daughter-in-law,motherin-law,father-in-law,sister-in-law,brother-in-law,orgrandparent.
ServicesthataresubmittedbytwodifferentprofessionalPractitionersforthesame
servicesperformedonthesamedateforthesameperson.
Asaresultof:
o AnInjury,Illness,disabilityorconditionresultingfromorcausedby:
§ anyactofdeclaredorundeclaredwar,or
§ beingengagedinactivemilitary,reservists’duties,NationalGuardorcivilian
auxiliaryforces.
o TheCoveredPersontakingpartinariot.
NUTRITIONALSUPPLEMENTS
Blendedfood,babyfood,orregularshelffoodwhenusedwithanenteralsystem;milk-orsoy-based
infantformulawithintactproteins;anyformula,whenusedfortheconvenienceofYouorYourfamily
members;nutritionalsupplementsoranyothersubstanceutilizedforthesolepurposeofweightlossor
gain,orforcaloricsupplementation,limitation,ormaintenance;oralsemisyntheticintact
protein/proteinisolates,naturalintactprotein/proteinisolates,andintactprotein/proteinisolates;food
additives,including,butnotlimitedto,thickeners,vitamins,fibersupplements,calorieorprotein
supplementsandlactosedigestionproducts,andnormalfoodproductsusedinthedietarymanagement
ofrarehereditarygeneticmetabolicdisorders.
ORALSURGERY
Exclusionsinclude,butarenotlimitedto:
• Servicesthatarepartofanorthodontictreatmentprogram;
• Servicesrequiredforcorrectionofanocclusaldefect;
• Servicesencompassingorthognathicorprognathicsurgicalprocedures;
• Removalofasymptomatic,non-impactedthirdmolars;and
• Orthodontiaandrelatedservices.
OTHERPAYERSOURCE
IninstanceswhenCCHPshouldbesecondarytoaprimarypayersource.
OUT-OF-NETWORK/NONPARTICIPATINGPROVIDERSExclusionsinclude:
• Ambulatorynon-emergent,non-urgentfollow-upcarefurnishedbyanOut-of-NetworkProvideror
PractitionersafteranEmergency;
• AcuteHospital(inpatientorobservation)follow-upcarefurnishedbyanOut-of-NetworkProvider
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Exclusions
EXCLUSIONSANDLIMITATIONS
NotallhealthcareservicesareCoveredServices.Thefollowingisalistofservicesthatarenotcovered.
orPractitionersafteranEmergency;
• TreatmentfurnishedbyanOut-of-NetworkProviderthatisinCCHP’sServiceArea.
Thisdoesnotapplyto:
• EmergencyServicesprovidedinanEmergencyroomorUrgentCareFacilitywhen,duetothe
CoveredPerson’slocationwhencarebecamenecessary,anIn-NetworkProviderorPractitioner
couldnotpracticallyfurnishthecare;
• UrgentCareprovidedinanUrgentCareFacilityoutsideCCHP’sServiceArea.
OVER-THE-COUNTERDRUGS
Food,foodsupplements,vitamins,andothernutritionalandover-the-counterelectrolytesupplements,
exceptotherwisesetforthinEnteralNutritionintheHomeintheCoveredServicessectionorwhen
coverageisrequiredbytheAffordableCareAct.
OTHERPRESCRIPTIONDRUGS
• Noauthorizationswillbeprovidedformedicationsthatarereportedbythemember,
Practitioner,orpharmacytobelost,misplaced,stolen,destroyed,ordamaged.
• Medicationsreceivedatnochargetothemember(workers’compensation,medications
purchasedwithamanufacturer’scoupon,etc.)willnotbecovered.
• Prescriptionsthatarewrittenmorethanayearagowillnotbecovered.YourPractitionerwill
needtowriteanewprescription.
• Antimalarialagentswhenusedforprevention.
• Compoundedproductscontainingexcludedingredients(examplesarecompoundedhormone
replacementtherapiesandcompoundednarcoticanalgesics).
• Needles/Syringes(otherthaninsulin).*
• Urinestrips(becauseOurdoctorsfeelbloodglucosestripsaremoreaccuratethanurinetest
stripsinmeasuringbloodglucose,urinestripsarenotacoveredbenefit).
Thisisnotacompletelistandtheremaybeothermedicationsthatarenotcovered.
*Pleasenotethat,undercertaincircumstances,Yourmedicalbenefitsmaycovertheitemsmarkedwith
anasterisk(*).Forinformationontheseitems,YoucancontactCustomerServiceatthenumberlisted
onthebackofYourmemberIDcard.
PERSONALCARE,COMFORTORCONVENIENCE
Comfortorconvenienceitems,forYouorYourcaretaker,evenifrecommendedbyaprofessional
Practitionerincluding,butnotlimitedtothefollowing:
• Airconditioners,airpurifiersandfiltersanddehumidifiers.
• Batteriesandbatterychargers.
• Beauty/barberservicesincludingwigsorhairpieces.
• Medical-gradebreastpumps.
• Carseats.
• Chairs,bathchairs,feedingchairs,toddlerchairs,chairliftsandrecliners.
• Continuousglucosemonitoringdevice.
• ElectricScooters.
• Exerciseequipmentandtreadmills.
• Fitness/Healthclubmemberships.
• Foodblenders.
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Exclusions
EXCLUSIONSANDLIMITATIONS
NotallhealthcareservicesareCoveredServices.Thefollowingisalistofservicesthatarenotcovered.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Guestservice.
Homemodificationssuchaselevators,handrailsandramps.
Hottubs,Jacuzzis,whirlpools,saunas.
Humidifiers.
Mattresses.
Medicalalertsystems.
Fullymotorizedbeds.
Musicdevices.
Personalcomputers.
Pillows.
Power-operatedvehicles.
Radios.
Stairliftsandstairglides.
Strollers,unlessdeterminedtobemedicallynecessaryduetodisability.
Safetyequipment.
Television.
Telephone.
Vehiclemodificationssuchasvanlifts.
Videoplayers.
PRIVATEDUTYNURSING
PrivateDutyNursingisnotcoveredunderanycircumstances.
REPRODUCTION
• Health services and associated expenses including prescription drugs for infertility evaluation,
diagnosis and treatments, includingassistedreproductivetechnology,regardlessofthereason
forthetreatment.
• Storageandretrievalofallreproductivematerials.Examplesincludeeggs,sperm,testicular
tissueandovariantissue.
• Thereversalofsterilizationandrelatedprocedures.
• Invitrofertilizationregardlessofthereasonfortreatment.
• Fetalreductionsurgery.
• Infertilitymedications.
• Collectionandstorageofumbilicalcordbloodandproducts.
TRANSPLANTS
• Healthservicesfororganandtissuetransplantsandallrelatedexpenses,exceptthosedescribed
underTransplantsintheCoveredServicessection.
• ServicesandsuppliesinconnectionwithcoveredtransplantsunlessPriorAuthorizedbyCCHP.
• HealthservicesconnectedwiththeremovalofanorganortissuefromYouforpurposesofa
transplanttoanotherperson.(Donorcoststhataredirectlyrelatedtoorganremovalare
payableforatransplantthroughtheorganrecipient'sBenefitsunderthisContract.)
•
Anyexperimentalorinvestigationaltransplantoranyothertransplant-liketechnologynotlisted
inthisContract.Anyresultingcomplicationsfromthese,andanyservicesandsuppliesrelatedto
suchexperimentalorinvestigationaltransplantationorcomplications,including,butnotlimited
to:highdosechemotherapy,radiationtherapyorimmunosuppressivedrugs.
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Exclusions
EXCLUSIONSANDLIMITATIONS
NotallhealthcareservicesareCoveredServices.Thefollowingisalistofservicesthatarenotcovered.
TRANSPORTATION
Non-emergencytransportation,includingviaambulanceproviderexceptassetforthinAmbulancesinthe
CoveredServicessection.
TREATMENTOUTSIDEOFTHEUNITEDSTATES
Treatmentfornon-emergencyornon-urgentservicesreceivedoutsideoftheUnitedStates.
TYPEOFCARE
• Multi-disciplinarypainmanagementprogramsprovidedonaninpatientbasisforacutepainor
forexacerbationofchronicpain.
• Restcures.
• Servicesofpersonalcareattendants.
VISION
Allvision-relatedservices(exceptwheresuchservicesarerequiredundertheAffordableCareAct),
including:
• Adultvisionexaminations,aswellasadulteyeglassesandcontactlenses,includingthosefor
prescribingorfittingeyeglassesorcontactlenses(exceptwhereYouhavecataracts,
keratoconus,oraphakia).
• Servicesforthecorrectionofmyopia(nearsightedness),hyperopia(farsightedness),or
astigmatism,including,butnotlimitedto,radialkeratotomy(refractivesurgery).
• Visiontrainingforcertaindiagnoses.
• Orthoptics.
WEIGHTREDUCTIONANDWEIGHTMODIFICATION
WeightreductionprogramsandproductsnotincludedinMedicalNutritionEducationintheCovered
Servicessection.Weightreductionprograms,includingallrelateddiagnostictestingandotherservices,
exceptwhensuchcoverageisrequiredbytheAffordableCareAct.Anti-obesitymedication,including,
butnotlimitedto,appetitesuppressantsandlipaseinhibitors. Weightmodification,orforsurgical
treatmentofobesity,includingwiringoftheteethandallformsofintestinalbypass.
WORKERS’COMPENSATION
TreatmentorservicesasaresultofanInjuryorIllnessarisingoutof,orinthecourseof,employmentfor
wageorprofit,iftheCoveredPersonisinsured,orisrequiredtobeinsured,byworkers'compensation
insurancepursuanttoapplicablestateorfederallaw.IfYouenterintoasettlementthatwaivesaCovered
Person’srighttorecoverfuturemedicalbenefitsunderaworkers'compensationlaworinsuranceplan,
thisexclusionwillstillapply.Intheeventthattheworkers'compensationinsurancecarrierdenies
coverageforaCoveredPerson’sworkers'compensationclaim,thisexclusionwillstillapplyunlessthat
denialisappealedtothepropergovernmentalagencyandthedenialisupheldbythatagency.
CCHP17.EOC
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Exclusions
PRESCRIPTIONDRUGBENEFITS
WhenYougotoapharmacythatparticipatesintheChildren’sCommunityHealthPlan(CCHP)network,
YouwillbeabletoreceivecoverageforYourprescriptionmedicationsfortheamountsoutlinedinthe
ScheduleofBenefits.
Tobeeligibleforbenefits,YoumustpurchaseYourprescriptiondrugsfromanin-networkretail
pharmacy,orthroughthemail-orderprogram.
RETAILPHARMACYNETWORK
CCHPprovidesabroadretailpharmacynetworkthatincludes:
• Nationalchainpharmacies,includingCVS,Kmart,Walgreens,Target,andWalmart.
• Anextensivenetworkofindependentpharmaciesandseveralregionalchainpharmacies.
Generally,Youcangotoaretailpharmacytogetmedications,includingmedicationsforillnessessuchas
acold,theflu,orstrepthroat.IfYouusearetailIn-NetworkPharmacy,thepharmacywillbillUsdirectly
forYourprescriptionandwillaskYoutopayanyapplicableCopayment,Deductible,orCoinsurance.
Remember,CCHPdoesnotcoverprescriptiondrugsobtainedfromanOut-of-NetworkPharmacy.To
locateanIn-NetworkPharmacynearYou,contactCustomerServicesatthephonenumberontheback
ofYourmemberidentificationcard,orvisit[http://TogetherCCHP.org].
HOWTOUSERETAILIN-NETWORKPHARMACIES
• TakeYourprescriptiontoaretailIn-NetworkPharmacyorhaveYourPractitionercallinthe
prescription.
• PresentYourIDcardatthepharmacy.
• VerifythatYourpharmacisthasaccurateinformationaboutYouandYourcoveredDependents
(includingYourdateofbirth).
• PaytherequiredCopaymentorCoinsuranceforYourprescription.
• SignforandreceiveYourprescription.
OBTAININGAREFILLFROMARETAILPHARMACY
Youmaypurchaseuptoaone-monthsupplyofaprescriptiondrugthroughanIn-NetworkPharmacyfor
oneCopayment,ora90-daysupplyforthreeCopayments,ortheapplicableCoinsurance.IfYour
Practitionerauthorizesaprescriptionrefill,simplybringtheprescriptionbottleorpackagetothe
pharmacyorcallthepharmacytoobtainYourrefill.
Remember,WewillnotcoverrefillsuntilYouhaveused75%ofYourmedication.Pleasewaituntilthat
timetorequestarefillofYourprescriptiondrug.Theserefillguidelinesalsoapplytorefillsfordrugsthat
arelost,stolen,ordestroyed.Replacementsforlost,stolen,ordestroyedprescriptionswillnotbe
coveredunlessanduntilYouwouldhavemetthe75%usagerequirementsetforthabovehadthe
prescriptionnotbeenlost,stolen,ordestroyed.
MAIL-ORDERPHARMACYSERVICES
Ifyoutakemaintenancemedicationsforachroniccondition,youcangetthemthroughOurmail-order
pharmacy.Maintenancemedicationsaredrugsthataretakenonaregular,long-termbasis.Thesemay
includedrugstotreathighbloodpressure,diabetes,asthma,highcholesterol,andmore.With
convenientmail-orderservice:
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PrescriptionDrugBenefits
PRESCRIPTIONDRUGBENEFITS
•
•
•
Youreceivea90-daysupplyofmostdrugs,plusrefills,asprescribedbyYourPractitioner.
Youusuallypayalowerout-of-pocketcostfora90-daysupplyatamail-orderpharmacythan
Youwouldpayataretailpharmacy.
YougetthesedrugsdeliveredrighttoYourdoor.
MaintenanceMedications:
• Youcanalsogetlong-termmaintenancemedicationsthroughOurmail-orderpharmacyat[1-
877-787-6279.]
SpecialtyMedications:
• Certainspecialtymedicationsmaybelimitedtoaone-monthsupplyandwillgenerallybe
dispensedonlyfromaspecialtypharmacynamedAccredo.
• YouandYourPractitionercancontinuetoordernewprescriptionsorrefillsforspecialtyand
injectablemedicationsbycalling[1-888-773-7376.]AccredoisavailableMondaythroughFriday
from8a.m.to9p.m.andSaturdayfrom9a.m.to1p.m.toassistYou.TTYusersshouldcall
[711.]
Whenusingthemail-orderorspecialtypharmacyservice,YoumustpayYourCopaymentorCoinsurance
beforereceivingYourprescriptionthroughthemail.TheCopaymentorCoinsuranceappliestoeach
originalprescriptionorrefill(name-brandorgeneric).
HOWTOUSETHEMAIL-ORDERSERVICE
ByMail:
• Youcanrequestamail-orderformbycallingCustomerServiceorbyrequestingtheform
through[CCHPConnect]attheCCHPwebsite[http://TogetherCCHP.org].
• Completetheinstructionsonthemail-orderform.
• MailthecompletedorderformwithYourrefillslipornewprescriptionandYourpayment
(check,moneyorder,orcreditcardinformation)totheaddressontheform.Allmajorcredit
cardsanddebitcardsareaccepted.
ByTelephone:
• ContactOurmail-orderCustomerServiceat[1-877-787-6279.]TheCustomerServicecenter
isavailable24hoursaday,sevendaysaweektoassistYou.TTYusersshouldcall[711].
ByInternet:
• YoucanaccessOurwebsitebylogginginto[CCHPConnect]foundat[http://TogetherCCHP.org].
YoumayenterYouruserIDonthehomepageinthememberlog-inbox.IfYouhavenot
accessed[CCHPConnect]before,signupforapersonal,secureuserIDandpasswordby
selecting“Newuserregistration”inthememberlog-inbox.Instructionsforsigningupand
accessing[CCHPConnect]areavailableonthispage.
• OnceYouhavesuccessfullysignedin,underthe“SmartHealthcare”section,selectthe
“Prescriptions”box.Youcanthenscrolldowntothe“Ordermaildeliveryforprescriptions”
option,expandthemenu,andchoosethe“Learnhowtosetupanewmail-orderprescription”
or“Refillanexistingmail-orderprescription.”Youwillthenbedirectedtothesecurewebsite;
followtheinstructionsprovidedontheirwebsitetocompletetheprocess.
IfYouneedYourlong-termmedicationrefilled,YoucanorderYourrefillbyphone,mail,ortheInternet
assetforthinthefollowingtable.BesuretoorderYourrefilltwotothreeweeksbeforeYoufinishYour
currentprescription.IfYouhavequestionsregardingthemail-orderservice,contactCustomerServiceat
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PrescriptionDrugBenefits
PRESCRIPTIONDRUGBENEFITS
thephonenumberonthebackofYourmemberidentificationcardorcall[1-877-787-6279.]TTY
usersshouldcall[711].
RefillsbyPhone
•
•
•
Useatouch-tonephonetoorderYour •
prescriptionrefillorinquireaboutthe
statusofYourorderat[1-877-787-
6279.]
•
Theautomatedphoneserviceis
available24hoursperday.
WhenYoucall,providethemember
identificationcode,birthdate,
prescriptionnumber,Yourcreditcard
number(includingexpirationdate),
•
andYourphonenumber.
RefillsbyMail
Attachtherefilllabel(You •
receivethislabelwith
everyorder)toYourmailorderform.
PayYourappropriate
Copaymentorothercost-
sharingamountvia
check,moneyorder,or
creditcard.
MailtheformandYour
paymentinthepre-
addressedenvelope.
RefillsbyInternet
Goto[CCHPConnect]
at
[http://TogetherCCHP.
org]andseethe
instructionsabove,
under“ByInternet.”
FORMULARY
Ourformularyisasix-tierformularyconsistingofaGenerictier,aPreferredBrandtier,aNon-Preferred
Brandtier,aSpecialtyDrugtier,aSelectGenerictier,anda$0Selecttier.BranddrugsonthePreferred
tierwillbeavailabletomembersatalowercostsharethannon-preferredbrands.Formularyhigh-cost
medicationssuchasbiologicalandinfusionsarecoveredintheSpecialtytier,whichmayhavestricter
days’-supplylimitationsthantheothertiers.The$0Selecttierhassomepreventivemedications
coveredatnocostsharetothemember.Somemedicationsmaybesubjecttoutilizationmanagement
criteria,includingbutnotlimitedto,PriorAuthorizationrules,quantitylimits,orsteptherapy.Selected
medicationsarenotcoveredwiththisformulary.
EXEMPTIONREQUESTS
Ifyou,yourdesigneeorYourPractitionerbelievethatyouneedaccesstoaclinicallyappropriatedrug
notcoveredinourformulary,thenyoumaysubmitarequestforcoverage(astandardrequest)toUsby
telephone,electronicfacsimile(i.e.fax)ormail.WewillmakeadecisiononYourrequestwithin72
hoursofOurreceiptofarequest.IfWegrantastandardrequestunderthisparagraph,thenWewill
providecoverageofthenon-formularydrugforthedurationoftheprescription,includingrefills.
You,yourdesigneeorYourPractitionermayalsorequestanexemptiononanexpeditedbasis(an
expeditedexemptionrequest)inexigentcircumstances.Anexigentcircumstanceexistswhenyouare
sufferingfromahealthconditionthatmayseriouslyjeopardizeyourlife,healthorabilitytoregain
maximumfunction,orwhenyouareundergoingacurrentcourseoftreatmentusinganon-formulary
drug.Wewillmakeadecisiononyourexpeditedexceptionrequestwithin24hoursorOurreceiptofan
expeditedrequest.IfWegrantanexceptionbasedonanexigentcircumstancerequest,Wewillprovide
coverageofthenon-formularydrugforthedurationoftheexigentcircumstance.
Ifwedenyastandardorexpeditedrequestforexemption,thenyou,yourdesigneeorYourPractitioner
mayrequestanexternalreviewunderourExternalReviewProgramdescribedintheComplaintsand
Appealssectionofthisdocument. Wewillmakeourdeterminationontheexternalexceptionrequest
within72hoursfollowOurreceiptofanexternalexemptionrequestiftheoriginalrequestwasa
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PrescriptionDrugBenefits
PRESCRIPTIONDRUGBENEFITS
standardexemptionrequest,orwithin24hoursfollowingOurreceiptoftheexternalexemptionrequest
iftheoriginalrequestwasanexpeditedexceptionrequest.
MEDICATIONSREQUIRINGPRIORAUTHORIZATION
SomemedicationsmayrequirethatYourPractitionerconsultwithUsbeforeheorsheprescribesthe
medicationforYou.WemustauthorizecoverageofthosemedicationsbeforeYoufilltheprescriptionat
thepharmacy.PleaseseethePharmacyBenefitGuideonOurwebsiteforalistingofmedicationsthat
requirePriorAuthorization.
QUANTITYLIMITS
CCHPhasestablishedquantitylimitsoncertainmedicationstocomplywiththeguidelinesestablishedby
theFoodandDrugAdministration(FDA)andtoencourageappropriateprescribinganduseofthese
medications.Also,theFDAhasapprovedsomemedicationstobetakenoncedailyinalargerdose
insteadofseveraltimesadayinasmallerdose.Forthesemedications,Yourbenefitplancoversonlythe
largerdoseperday.
ADDITIONALCOVERAGEINFORMATION
YourpharmacyBenefitsmaycoveradditionalmedicationsandsuppliesandmayexcludemedications
thatareotherwiselistedonYourformulary.PleaseseetheonlinePharmacyBenefitGuidefora
completelistofcovereddrugs. YourpharmacyBenefitsmayalsoincludespecificcost-sharingprovisions
forcertaintypesofmedicationsormayofferspecialdeductionsincost-sharingforparticipatingin
certainhealthmanagementprograms.Pleasereadthissectioncarefullytodetermineadditional
coverageinformationspecifictoYourBenefits.
•
•
•
•
YourpharmacyBenefitsincludescoveragefororalcontraceptives.
YourpharmacyBenefitsincludecoverageforprescriptiondrugsthatareapprovedbytheFDAfor
thetreatmentofHIV(HumanImmunodeficiencyVirus)infectionoraSicknessarisingfromorrelated
toHIVinfectionandinvestigationalnewdrugsthatareinorhavecompletedaphase3clinical
investigationandareprescribedandadministeredinaccordancewiththetreatmentprotocol
approvedfortheinvestigationalnewdruginthetreatmentofHIVinfectionoraSicknessarising
fromorrelatedtoHIVinfection.
YourpharmacyBenefitsincludecoverageforprescribed,orallyadministeredcancerchemotherapy
medicationusedtokillorslowthegrowthofcancerouscells.Thecoveragefororallyadministered
cancerchemotherapymedicationswillbeprovidedonabasisnolessfavorablethanthatprovidedfor
intravenouslyadministeredorinjectedcancerchemotherapymedicationsthatarecoveredunderthe
OutpatientServicesprovisionoftheCoveredServicessection.
YourpharmacyBenefitsincludescoverageforspecialcost-sharingprovisionsforchoosingbrand-
nameovergenericdrugs:
o AccordingtoYourformulary,genericdrugswillbesubstitutedforallbrand-namedrugsthat
haveagenericversionavailable.
o Ifthebrand-namedrugisdispensedinsteadofthegenericequivalent,Youmustpaythe
CopaymentorCoinsuranceassociatedwiththebrand-namedrugaswellastheretailprice
differencebetweenthebrand-namedrugandthegenericdrug.
PleaseseetheonlinePharmacyBenefitGuideformoreinformation.Youcanrequestaprintedcopybe
mailedtoYoubycallingtheCustomerServicenumberonthebackofYourIDcard.
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PrescriptionDrugBenefits
COORDINATIONOFBENEFITS
BENEFITSWHENYOUHAVECOVERAGEUNDERMORETHANONEPLAN
ThissectiondescribeshowBenefitsunderthisContractwillbecoordinatedwithBenefitsunderany
otherpolicyorplanthatprovidesBenefitsorservicesformedical,pharmacy,ordentalcareor
treatmenttoaCoveredPerson.AnysuchpolicyorplaniscalledthePrimaryPlan.
WHENCOORDINATIONOFBENEFITSAPPLIES
ThisCoordinationofBenefits(COB)provisionapplieswhenapersonhashealthcarecoverageunder
morethanonepolicyorplan.
APrimaryPlanmustpayBenefitsinaccordancewithitspolicytermswithoutregardtothepossibility
thatthisContractmaycoversomeexpenses.ThisContractpaysafterthePrimaryPlan,andmayreduce
theBenefitsitpayssothatpaymentsfromallcoveragedonotexceed100%ofthetotalAllowable
Expense.
AllowableExpenseisahealthcareexpense,includingDeductibles,coinsuranceandcopayments,
thatiscoveredatleastinpartbyanyaPrimaryPlanandthisContract.Whenaplanprovides
Benefitsintheformofservices,thereasonablecashvalueofeachservicewillbeconsideredan
AllowableExpenseandabenefitpaid.Anexpensethatisnotcoveredbyanyplancoveringthe
personisnotanAllowableExpense.Inaddition,anyexpensethataproviderbylaworinaccordance
withacontractualagreementisprohibitedfromchargingaCoveredPersonisnotanAllowable
Expense.ThefollowingareexamplesofexpensesorservicesthatarenotAllowableExpenses:
1. Thedifferencebetweenthecostofasemi-privatehospitalroomandaprivateroomisnotan
AllowableExpenseunlessoneoftheplansprovidescoverageforprivatehospitalroom
expenses.
2. Ifapersoniscoveredbytwoormoreplansthatcomputetheirbenefitpaymentsonthebasisof
usualandcustomaryfeesorrelativevalueschedulereimbursementmethodologyorother
similarreimbursementmethodology,anyamountinexcessofthehighestreimbursement
amountforaspecificbenefitisnotanAllowableExpense.
3. IfapersoniscoveredbytwoormoreplansthatprovideBenefitsorservicesonthebasisof
negotiatedfees,anamountinexcessofthehighestofthenegotiatedfeesisnotanAllowable
Expense.
4. IfthePrimaryPlancalculatesitsBenefitsorservicesonthebasisofusualandcustomaryfeesor
relativevalueschedulereimbursementmethodologyorothersimilarreimbursement
methodology,thePrimaryPlan’spaymentarrangementshallbetheAllowableExpenseforboth
plans.
5. TheamountofanybenefitreductionbythePrimaryPlanbecauseaCoveredPersonhasfailedto
complywiththePlanprovisionsisnotanAllowableExpense.Examplesofthesetypesofplan
provisionsincludesecondsurgicalopinions,precertificationofadmissionsandpreferred
providerarrangements.
EFFECTSONTHEBENEFITSOFTHISPLAN
A. WemayreduceBenefitsunderthisContractsothatthetotalBenefitspaidorprovidedbyallplans
arenotmorethanthetotalAllowableExpenses.Indeterminingtheamounttobepaidforanyclaim,
WewillcalculatetheBenefitsWewouldhavepaidintheabsenceofotherhealthcarecoverageand
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CoordinationofBenefits
COORDINATIONOFBENEFITS
applythatcalculatedamounttoanyAllowableExpenseunderthisContractthatisunpaidbythe
PrimaryPlan.WemaythenreducepaymentunderthisContractbytheamountsothat,when
combinedwiththeamountpaidbythePrimaryPlan,thetotalBenefitspaidorprovidedbyallplans
fortheclaimdonotexceedthetotalAllowableExpenseforthatclaim.Inaddition,Wewillcreditto
anyDeductibleunderthisContractanyamountsWewouldhavecreditedtotheDeductibleinthe
absenceofotherhealthcarecoverage.
B.WereduceBenefitsunderthisContractasdescribedbelowforCoveredPersonswhoareeligiblefor
MedicarewhenMedicarewouldbethePrimaryPlan.MedicareBenefitsaredeterminedasifthefull
amountthatwouldhavebeenpayableunderMedicarewasactuallypaidunderMedicare,evenif:
1. ThepersonisentitledtobutnotenrolledinMedicare.MedicareBenefitsaredeterminedasif
thepersonwerecoveredunderMedicarePartsAandB.
2. ThepersonisenrolledinaMedicareAdvantage(MedicarePartC)planandreceivesnon-
coveredservicesbecausethepersondidnotfollowallrulesofthatplan.MedicareBenefitsare
determinedasiftheserviceswerecoveredunderMedicarePartsAandB.
3. Thepersonreceivesservicesfromaproviderwhohaselectedtoopt-outofMedicare.Medicare
BenefitsaredeterminedasiftheserviceswerecoveredunderMedicarePartsAandBandthe
providerhadagreedtolimitchargestotheamountofchargesallowedunderMedicarerules.
4. TheservicesareprovidedinanyfacilitythatisnoteligibleforMedicarereimbursements,
includingaVeteransAdministrationfacility,facilityoftheUniformedServices,orotherfacilityof
theFederalgovernment.MedicareBenefitsaredeterminedasiftheserviceswereprovidedbya
facilitythatiseligibleforreimbursementunderMedicare.
5. ThepersonisenrolledunderaplanwithaMedicareMedicalSavingsAccount.MedicareBenefits
aredeterminedasifthepersonwerecoveredunderMedicarePartsAandB.
RIGHTTORECEIVEANDRELEASENEEDEDINFORMATION
CertainfactsabouthealthcarecoverageandservicesareneededtoapplytheseCOBrulesandto
determineBenefitspayableunderthisContractandBenefitspayableunderotherplans.Wemaygetthe
factsweneedfrom,orgivethemto,otherorganizationsorpersonsforthepurposeofapplyingthese
rulesanddeterminingBenefitspayableunderThisPlanandBenefitspayableunderotherplanscovering
thepersonclaimingBenefits.
Weneednottell,orgettheconsentof,anypersontodothis.EachpersonclaimingBenefitsunderthis
ContractmustgiveusanyfactsweneedtoapplythoserulesanddetermineBenefitspayable.IfYoudo
notprovideustheinformationweneedtoapplytheserulesanddeterminetheBenefitspayable,Your
claimforBenefitswillbedenied.
PAYMENTSMADE
Apaymentmadeunderanotherplanmayincludeanamountthatshouldhavebeenpaidunderthis
Contract.Ifitdoes,wemaypaythatamounttotheorganizationthatmadethepayment.Thatamount
willthenbetreatedasthoughitwereaBenefitpaidunderthisContract.Wewillnothavetopaythat
amountagain.Theterm"paymentmade"includesprovidingBenefitsintheformofservices,inwhich
case"paymentmade"meansreasonablecashvalueoftheBenefitsprovidedintheformofservices.
RIGHTOFRECOVERY
IftheamountofthepaymentsWemadeismorethanweshouldhavepaidunderthisCOBprovision,
Wemayrecovertheexcessfromoneormoreofthepersonswehavepaidorforwhomwehavepaid;or
anyotherpersonororganizationthatmayberesponsiblefortheBenefitsorservicesprovidedforthe
CCHP17.EOC
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CoordinationofBenefits
COORDINATIONOFBENEFITS
CoveredPerson.The"amountofthepaymentsmade"includesthereasonablecashvalueofanyBenefits
providedintheformofservices.
WHENMEDICAREISSECONDARY
IfaCoveredPersonhasotherhealthinsurancewhichisdeterminedtobeprimarytoMedicare,then
BenefitspayableunderthisContractwillbebasedonMedicare’sreducedBenefits.Innoeventwillthe
combinedBenefitspaidunderthesecoveragesexceedthetotalMedicareEligibleExpenseforthe
serviceoritem.SeetheLegalProvisionssectionofthisContractformoreinformation.
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CoordinationofBenefits
LEGALPROVISIONS
YOURRELATIONSHIPWITHUS
InordertomakechoicesaboutYourhealthcarecoverageandtreatment,Webelievethatitisimportant
forYoutounderstandhowWeinteractwithYourbenefitplanandhowitmayaffectYou.Wehelp
financeoradministerthebenefitplaninwhichYouareenrolled.Wedonotprovidemedicalservicesor
maketreatmentdecisions.Thismeans:
• WedonotdecidewhatcareYouneedorwillreceive.YouandYourPractitionermakethose
decisions.
• WecommunicatetoYoudecisionsaboutwhetherYourbenefitplanwillcoverorpayforthe
healthcarethatYoumayreceive.Theplanpaysforcoveredhealthservices,whicharemore
fullydescribedinthisevidenceofcoverage.
• TheplanmaynotpayforalltreatmentsYouorYourPractitionermaybelievearenecessary.If
theplandoesnotpay,Youwillberesponsibleforthecost.
WemayuseindividuallyidentifiableinformationaboutYoutoidentifyforYou(andYoualone)
procedures,productsorservicesthatYoumayfindvaluable.Wewilluseindividuallyidentifiable
informationaboutYouaspermittedorrequiredbylaw,includinginOuroperationsandinOurresearch.
Wewillusede-identifieddataforcommercialpurposesincludingresearch.PleaserefertoOurNoticeof
PrivacyPracticesfordetails.
OURRELATIONSHIPWITHPRACTITIONERS
Wedonotprovidehealthcareservicesorsupplies,nordoWepracticemedicine.Instead,Wearrangefor
healthcarePractitionerstoparticipateinanetworkandWepayBenefits.Networkprovidersare
independentPractitionerswhoruntheirownofficesandfacilities.Ourcredentialingprocessconfirms
publicinformationaboutthePractitioners’licensesandothercredentials,butdoesnotassurethequality
oftheservicesprovided.TheyarenotOuremployeesnordoWehaveanyotherrelationshipwith
networkPractitionerssuchasprincipal-agentorjointventure.Wearenotliableforanyactoromissionof
anyPractitioner.
YOURRELATIONSHIPWITHPRACTITIONERS
TherelationshipbetweenYouandanyPractitioneristhatofproviderandpatient.
• YouareresponsibleforchoosingYourownPractitioner.
• Youareresponsibleforpaying,directlytoYourPractitioner,anyamountidentifiedasaCovered
Personresponsibility,includingCopayments,Coinsurance,anyDeductibleandanyamountthat
exceedstheMaximumAllowedAmount.
• Youareresponsibleforpaying,directlytoYourPractitioner,thecostofanynon-covered
healthservice.
• YoumustdecideifanyPractitionertreatingYouisrightforYou.ThisincludesnetworkPractitioners
YouchooseandPractitionerstowhomYouhavebeenreferred.
• YoumustdecidewithYourPractitionerwhatcareYoushouldreceive.
• YourPractitionerissolelyresponsibleforthequalityoftheservicesprovidedtoYou.
NOTICE
WeprovidewrittennoticeregardingadministrationoftheContracttoYouastheauthorized
representativeoftheContractandthatnoticeisdeemednoticetoallaffectedContractHoldersand
theirCoveredDependents.
STATEMENTSBYCOVEREDPERSONS
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LegalProvisions
LEGALPROVISIONS
AllstatementsmadebyaCoveredPersonshall,intheabsenceoffraud,bedeemedrepresentationsand
notwarranties.
INCENTIVESTOPROVIDERS
WepayNetworkPractitionersthroughvarioustypesofcontractualarrangements,someofwhich
mayincludefinancialincentivestopromotethedeliveryofhealthcareinacostefficientand
effectivemanner.ThesefinancialincentivesarenotintendedtoaffectYouraccesstohealthcare.
WeusevariouspaymentmethodstopayspecificNetworkPractitioners.Fromtimetotime,the
paymentmethodmaychange.IfYouhavequestionsaboutwhetherYourNetworkPractitioner’s
contractwithUsincludesanyfinancialincentives,WeencourageYoutodiscussthosequestionswith
YourPractitioner.YoumayalsocontactUsatthetelephonenumberonYourIDcard.Wecanadvise
whetherYourNetworkPractitionerispaidbyanyfinancialincentive,includingthoselistedabove;
however,thespecifictermsofthecontract,includingratesofpayment,areconfidentialandcannotbe
disclosed.
INCENTIVESTOYOU
SometimesWemayoffercouponsorotherincentivestoencourageYoutoparticipateinvarious
wellnessprogramsorcertaindiseasemanagementprograms.Thedecisionaboutwhetherornotto
participateisYoursalonebutWerecommendthatYoudiscussparticipatinginsuchprogramswithYour
Practitioner.TheseincentivesarenotBenefitsanddonotalteroraffectYourBenefits.ContactUsifYou
haveanyquestions.
DISCOUNTEDORFREENON-INSURANCEPROGRAMS
Wemayelecttofurnishorparticipateinprogramswithotherorganizationsthatfurnish
ContractHolderswhomeetcommoncriteriaorrequirementsdeterminedbyUswithdiscountcards,
vouchers,coupons,orothergoods,servicesorprogramsthatmaybeofferedorprovidedto
CoveredPersonsatnochargeorareducedchargeforaperiodoftimedeterminedbyUs.Wemay
provideYouwithaccesstodiscountswithcertainhealthcarePractitionersandsuppliers
negotiatedbyUs.
INTERPRETATIONOFBENEFITS
Wehavethesoleandexclusivediscretiontodoallofthefollowing:
• InterpretBenefitsundertheContract.
• Interprettheotherterms,conditions,limitationsandexclusionssetoutintheContract,
includingthisEvidenceofCoverage,theScheduleofBenefitsandanyRidersand/or
Amendments.
• MakefactualdeterminationsrelatedtotheContractanditsBenefits.
Wemaydelegatethisdiscretionaryauthoritytootherpersonsorentitiesthatprovideservicesinregard
totheadministrationoftheContract.
Incertaincircumstances,forpurposesofoverallcostsavingsorefficiency,Wemay,inOurdiscretion,
offerBenefitsforservicesthatwouldotherwisenotbeCoveredHealthServices.ThefactthatWedoso
inanyparticularcaseshallnotinanywaybedeemedtorequireUstodosoinothersimilarcases.
ADMINISTRATIVESERVICES
Wemay,inOursolediscretion,arrangeforvariouspersonsorentitiestoprovideadministrativeservices
in regard to the Contract, such as claims processing. The identity of the service Practitioners and the
CCHP17.EOC
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LegalProvisions
LEGALPROVISIONS
natureoftheservicestheyprovidemaybechangedfromtimetotimeinOursolediscretion.Wearenot
requiredtogiveYoupriornoticeofanysuchchange,norareWerequiredtoobtainYourapproval.You
mustcooperatewiththosepersonsorentitiesintheperformanceoftheirresponsibilities.
AMENDMENTSTOTHECONTRACT
Totheextentpermittedbylaw,Wereservetheright,inOursolediscretionandwithoutYourapproval,
tochange,interpret,modify,withdraworaddBenefitsorterminatetheContract.
AnyprovisionoftheContractwhich,onitsEffectiveDate,isinconflictwiththerequirementsofstateor
Federalstatutesorregulations(ofthejurisdictioninwhichtheContractisdelivered)isherebyamended
toconformtotheminimumrequirementsofsuchstatutesandregulations.
NootherchangemaybemadetotheContractunlessitismadebyanAmendmentorRiderwhichhas
beensignedbyoneofOurofficers.Allofthefollowingconditionsapply:
•
•
•
•
•
AmendmentstotheContractareeffective31daysafterWesendwrittennoticetotheContract
Holder.
AmendmentsthatresultinareductionofBenefitswillbeeffectiveupon60dayspriorwritten
notice.
RidersareeffectiveonthedateWespecify.
NoagenthastheauthoritytochangetheContractortowaiveanyofitsprovisions.
NoonehasauthoritytomakeanyoralchangesorAmendmentstotheContract.
INFORMATIONANDRECORDS
WemayuseYourindividuallyidentifiablehealthinformationtoadministertheContractandpayclaims,
toidentifyprocedures,products,orservicesthatYoumayfindvaluable,andasotherwisepermittedor
requiredbylaw.WemayrequestadditionalinformationfromYoutodecideYourclaimforBenefits.We
willkeepthisinformationconfidential.WemayalsouseYourde-identifieddataforcommercial
purposes,includingresearch,aspermittedbylaw.MoredetailabouthowWemayuseordiscloseYour
informationisfoundinOurNoticeofPrivacyPractices.
ByacceptingBenefitsundertheContract,Youauthorizeanddirectanypersonorinstitutionthathas
providedservicestoYoutofurnishUswithallinformationorcopiesofrecordsrelatingtotheservices
providedtoYou.Wehavetherighttorequestthisinformationatanyreasonabletime.Thisappliestoall
CoveredPersons,includingCoveredDependentswhetherornottheyhavesignedtheContractHolder’s
enrollmentform.Weagreethatsuchinformationandrecordswillbeconsideredconfidential.
Wehavetherighttoreleaseanyandallrecordsconcerninghealthcareserviceswhicharenecessaryto
implementandadministerthetermsoftheContract,forappropriatemedicalrevieworquality
assessment,orasWearerequiredtodobylaworregulation.DuringandafterthetermoftheContract,
WeandOurrelatedentitiesmayuseandtransfertheinformationgatheredundertheContractinade-
identifiedformatforcommercialpurposes,includingresearchandanalyticpurposes.PleaserefertoOur
NoticeofPrivacyPractices.
ForcompletelistingsofYourmedicalrecordsorbillingstatementsWerecommendthatYoucontactYour
healthcarePractitioner.PractitionersmaychargeYoureasonablefeestocovertheircostsforproviding
recordsorcompletingrequestedforms.IfYourequestmedicalformsorrecordsfromUs,Wealsomay
chargeYoureasonablefeestocovercostsforcompletingtheformsorprovidingtherecords.Insome
cases,aspermittedbylaw,Wewilldesignateotherpersonsorentitiestorequestrecordsorinformation
fromorrelatedtoYou,andtoreleasethoserecordsasnecessary.Ourdesigneeshavethesamerightsto
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LegalProvisions
thisinformationasWehave.
LEGALPROVISIONS
EXAMINATIONOFCOVEREDPERSONS
WehavetherighttohaveahealthcarePractitionerofOurchoiceexamineaCoveredPersonatanytime
regardingaclaimforbenefitsorwhenauthorizationisrequestedunderthePriorAuthorizationsection.
TheseexamswillbepaidbyUs.Wealsohavetheright,incaseofdeath,tohaveanautopsydonewhere
itisnotprohibitedbylaw.
WORKERS'COMPENSATIONNOTAFFECTED
BenefitsprovidedundertheContractdonotsubstituteforanddonotaffectanyrequirementsfor
coveragebyworkers'compensationinsurance.
MEDICAREELIGIBILITY
BenefitsundertheContractarenotintendedtosupplementanycoverageprovidedbyMedicare.
Nevertheless,insomecircumstancesCoveredPersonswhoareeligiblefororenrolledinMedicaremay
alsobeenrolledundertheContract.
IfYouareeligiblefororenrolledinMedicare,pleasereadthefollowinginformationcarefully.
IfYouareeligibleforMedicareonaprimarybasis(MedicarepaysbeforeBenefitsundertheContract),
YoushouldenrollinandmaintaincoverageunderbothMedicarePartAandPartB.IfYoudon'tenroll
andmaintainthatcoverage,andifWearethesecondarypayerasdescribedintheCoordinationof
Benefitssection,WewillpayBenefitsundertheContractasifYouwerecoveredunderbothMedicare
PartAandPartB.Asaresult,YouwillberesponsibleforthecoststhatMedicarewouldhavepaidand
Youwillincuralargerout-of-pocketcost.
IfYouareenrolledinaMedicareAdvantage(MedicarePartC)planonaprimarybasis(Medicarepays
beforeBenefitsundertheContract),YoushouldfollowallrulesofthatplanthatrequireYoutoseek
servicesfromthatplan'sparticipatingPractitioners.WhenWearethesecondarypayer,Wewillpayany
BenefitsavailabletoYouundertheContractasifYouhadfollowedallrulesoftheMedicareAdvantage
plan.YouwillberesponsibleforanyadditionalcostsorreducedBenefitsthatresultfromYourfailureto
followtheserules,andYouwillincuralargerout-of-pocketcost.
SUBROGATIONANDREIMBURSEMENT
Subrogationisthesubstitutionofonepersonorentityintheplaceofanotherwithreferencetoalawful
claim,demandorright.ImmediatelyuponpayingorprovidinganyBenefits,Weshallbesubrogatedto
shallsucceedtoallrightsofrecovery,underanylegaltheoryofanytypeforthereasonablevalueofany
servicesandBenefitsWeprovidedtoYou,fromanyorallofthefollowinglistedbelow.
InadditiontoanysubrogationrightsandinconsiderationofthecoverageprovidedbythisCertificate,
WeshallalsohaveanindependentrighttobereimbursedbyYouforthereasonablevalueofany
servicesandBenefitsWeprovidetoYou,fromanyorallofthefollowinglistedbelow.
• Thirdparties,includinganypersonallegedtohavecausedYoutosufferinjuriesordamages.
• AnypersonorentitywhoisormaybeobligatedtoprovideBenefitsorpaymentstoYou,
includingBenefitsorpaymentsforunderinsuredoruninsuredmotoristprotection,no-faultor
traditionalautoinsurance,medicalpaymentcoverage(auto,homeownersorotherwise),
workers'compensationcoverage,otherinsurancecarriersorthirdpartyadministrators.
• AnypersonorentitywhoisliableforpaymenttoYouonanyequitableorlegalliabilitytheory.
Thesethirdpartiesandpersonsorentitiesarecollectivelyreferredtoas"ThirdParties."
TheseSubrogationandReimbursementrightsgrantedtoUsshallnotapplyuntilsuchtimeasYouhave
73
LegalProvisions
CCHP17.EOC
LEGALPROVISIONS
been“madewhole”.YouaremadewholeifaclaimresultsinpaymenttoYou,bywayofsettlement,
compromiseorjudgmentofanamountlessthanthecombinedtotalofanyavailablethirdparty
payments,includingliability,uninsuredorunderinsuredmotoristpolicyproceeds.Intheeventofthe
settlementorcompromiseofadisputedclaim,Youaremadewholewhenaclaimresultsinpaymentfor
lessthanthetotalavailablethirdpartyproceedsafterreducingYourtotaldamagestoaccountforany
contributorynegligenceattributabletoYou.WeandYoueachhavearighttoahearingbyatrialjudgeif
thereisadisputeastotheamountofcontributorynegligencereasonablyattributabletoYou.
Youagreeasfollows:
• ThatYouwillcooperatewithUsinprotectingOurlegalandequitablerightstosubrogationand
reimbursement,including:
o ProvidinganyrelevantinformationrequestedbyUs.
o Signingand/ordeliveringsuchdocumentsasWeorOuragentsreasonablyrequestto
securethesubrogationandreimbursementclaim.
o Respondingtorequestsforinformationaboutanyaccidentorinjuries.
o Makingcourtappearances.
o ObtainingOurconsentorOuragents'consentbeforereleasinganypartyfromliabilityor
paymentofmedicalexpenses.
• ThatWehavetheauthorityanddiscretiontoresolvealldisputesregardingtheinterpretationof
thelanguagestatedherein.
• Thatnocourtcostsorattorneys'feesmaybedeductedfromOurrecoverywithoutOurexpress
writtenconsent;anyso-called"FundDoctrine"or"CommonFundDoctrine"or"Attorney'sFund
Doctrine"shallnotdefeatthisright,andWearenotrequiredtoparticipateinorpaycourtcosts
orattorneys'feestotheattorneyhiredbyYoutopursueYourdamage/personalInjuryclaim.
• ThatafterYouhavebeenfullycompensatedormadewhole,WemaycollectfromYouthe
proceedsofanyfullorpartialrecoverythatYouorYourlegalrepresentativeobtain,whetherin
theformofasettlement(eitherbeforeorafteranydeterminationofliability)orjudgment,with
suchproceedsavailableforcollectiontoincludeanyandallamountsearmarkedasnon-
economicdamagesettlementorjudgment.
• ThatBenefitspaidbyUsmayalsobeconsideredtobeBenefitsadvanced.
• ThatYouagreethatifYoureceiveanypaymentfromanypotentiallyresponsiblepartyasaresult
ofanInjuryorillness,whetherbysettlement(eitherbeforeorafteranydeterminationof
liability),orjudgment,Youwillserveasaconstructivetrusteeoverthefunds,andfailuretohold
suchfundsintrustwillbedeemedasabreachofYourdutieshereunder.
• ThatYouoranauthorizedagent,suchasYourattorney,mustholdanyfundsdueandowingUs,
asstatedherein,separatelyandalone,andfailuretoholdfundsassuchwillbedeemedasa
breachofcontract,andmayresultintheterminationofhealthBenefitsortheinstigationof
legalactionagainstYou.
• ThatWemaysetofffromanyfutureBenefitsotherwiseprovidedbyUsthevalueofBenefits
paidoradvancedunderthissectiontotheextentnotrecoveredbyUs.
• ThatYouwillnotacceptanysettlementthatdoesnotfullycompensateorreimburseUswithout
Ourwrittenapproval,norwillYoudoanythingtoprejudiceOurrightsunderthisprovision.
• ThatYouwillassigntoUsallrightsofrecoveryagainstThirdParties,totheextentofthe
reasonablevalueofservicesandBenefitsWeprovided,plusreasonablecostsofcollection.
• ThatOurrightswillbeconsideredasthefirstpriorityclaimagainstThirdParties,including
tortfeasorsfromwhomYouareseekingrecovery,tobepaidbeforeanyotherofYourclaimsare
paid.
• ThatWemay,atOuroption,takenecessaryandappropriateactiontopreserveOurrightsunder
thesesubrogationprovisions,includingfilingsuitinYourname,whichdoesnotobligateUsin
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LEGALPROVISIONS
•
•
•
anywaytopayYoupartofanyrecoveryWemightobtain.
ThatWeshallnotbeobligatedinanywaytopursuethisrightindependentlyoronYourbehalf.
ThatinthecaseofYourwrongfuldeath,theprovisionsofthissectionwillapplytoYourestate,
thepersonalrepresentativeofYourestateandYourheirsorbeneficiaries.
Thattheprovisionsofthissectionapplytotheparents,guardian,orotherrepresentativeofa
DependentchildwhoincursaSicknessorInjurycausedbyaThirdParty.Ifaparentorguardian
maybringaclaimfordamagesarisingoutofaminor'sInjury,thetermsofthissubrogationand
reimbursementclauseshallapplytothatclaim.
REFUNDOFOVERPAYMENTS
IfWepayBenefitsforexpensesincurredonaccountofaCoveredPerson,thatCoveredPerson,orany
otherpersonororganizationthatwaspaid,mustmakearefundtoUsifanyofthefollowingapply:
• AllorsomeoftheexpenseswerenotpaidbytheCoveredPersonordidnotlegallyhavetobe
paidbytheCoveredPerson.
• AllorsomeofthepaymentWemadeexceededtheBenefitsundertheContract.
• Allorsomeofthepaymentwasmadeinerror.
TherefundequalstheamountWepaidinexcessoftheamountWeshouldhavepaidunderthe
Contract.Iftherefundisduefromanotherpersonororganization,theCoveredPersonagreestohelpUs
gettherefundwhenrequested.
IftheCoveredPerson,oranyotherpersonororganizationthatwaspaid,doesnotpromptlyrefundthe
fullamount,WemayreducetheamountofanyfutureBenefitsfortheCoveredPersonthatarepayable
undertheContract.Thereductionswillequaltheamountoftherequiredrefund.Wemayhaveother
rightsinadditiontotherighttoreducefutureBenefits.
LIMITATIONOFACTION
Nosuitoractionatlaworinequitycanbebroughtlaterthan3yearsfromthedatewhenproofofloss
isrequiredtobefurnishedunderthisContract(seeSection5ofthisContractentitledHowToObtain
CoveredServices).
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OTHERPROVISIONS
ENTIRECONTRACT
ThisevidenceofcoverageisissuedtotheContractHolder.Theentirecontractofinsuranceincludesthe
evidenceofcoverage,thescheduleofBenefits,aCoveredPerson’senrollmentform,andanyridersand
endorsements.
CONTRACTCHANGES
NochangeintheContractwillbevalidunlessapprovedbyoneofOurexecutiveofficersandincluded
withorissuedasasupplementtothisContract.NoinformationprovidedbytheCustomerService
departmentwillchangeyourcoverage,obligations,orresponsibilitiesundertheContract.Noagentor
otheremployeeofOurcompanyhasauthoritytowaiveorchangeanyplanprovisionorwaiveanyother
applicableenrollmentorapplicationrequirements.
CLERICALERROR
IfaclericalerrorismadebyUs,itwillnotaffecttheinsurancetowhichaCoveredPersonisentitled.
Delayorfailuretoreportterminationofanyinsurancewillnotcontinuetheinsuranceinforcebeyond
thedateitwouldhaveterminatedaccordingtothisContract.
Thepremiumchargeswillbeadjustedasrequired,butnotformorethantwoyearspriortothedatethe
errorwasfound.Ifthepremiumwasoverpaid,Wewillrefundthedifference.Ifthepremiumwas
underpaid,thedifferencemustbepaidtoUswithin60daysofOurnotifyingYouoftheerror.
CONFORMITYWITHSTATESTATUTES
Ifthisplan,onitsEffectiveDate,isinconflictwithanyapplicablefederallawsorlawsofthestatewhere
itisissued,itischangedtomeettheminimumrequirementsofthoselaws.Intheeventthatnewor
applicablestateorfederallawsareenactedwhichconflictwithcurrentprovisionsofthisplan,the
provisionsthatareaffectedwillbeadministeredinaccordancewiththenewapplicablelaws,despite
anythingintheplantothecontrary.
ENFORCEMENTOFPLANPROVISIONS
FailurebyUstoenforceorrequirecompliancewithanyprovisionwithinthisplanwillnotwaive,modify
orrenderanyprovisionunenforceableatanyothertime,whetherthecircumstancesarethesameor
not.
MISSTATEMENTS
IfaCoveredPerson’smaterialinformationhasbeenmisstatedandthepremiumamountwouldhave
beendifferenthadthecorrectinformationbeendisclosed,anadjustmentinpremiumsmaybemade
basedonthecorrectedinformation.Inadditiontoadjustingfuturepremiums,Wemayrequirepayment
ofpastpremiumsattheadjustedratetocontinuecoverage.IftheCoveredPerson’sageismisstatedand
coveragewouldnothavebeenissuedbasedontheCoveredPerson’strueage,Oursoleliabilitywillbeto
refundallofthepremiumspaidforthatCoveredPerson’scoverage,minustheamountofanyBenefits
paidbyUs.
RECISSIONOFINSURANCEAND/ORDENIALOFCLAIM
WithinthefirsttwoyearsaftertheEffectiveDateofcoverage,WehavetherighttomodifyYour
Contractofinsurancecoverageand/ordenyaclaimforaCoveredPersoniftheenrollmentformcontains
anomissionormisrepresentation,whetherintendedornot,whichWedeterminetobematerial.We
alsoreservetherighttorescindaContractofinsuranceand/ordenyaclaimifCoveredPersonhas
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OTHERPROVISIONS
performedanactorpracticethatconstitutesfraudorintentionalmisrepresentationofmaterialfactat
anytimeduringthecoverageperiod.
FORUM
AnylawsuitsordisputesarisingunderthetermsoftheContractmustbebroughtintheUnitedStates
DistrictCourtfortheEasternDistrictofWisconsin.
ASSIGNMENTOFBENEFITS
ThiscoverageisjustforYouand/orYoureligibleDependents. BenefitsmaybeassignedtoaPractitioner
totheextentallowedbyWisconsininsurancelawandbyotherprovisionsinthisContract.
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OtherProvisions
COMPLAINTSANDAPPEALS
YouhavetherighttocomplainaboutservicesofferedthroughChildren’sCommunityHealthPlanorthe
Practitioners and providersinOurnetwork,oranyotherissue.YoualsohavetherighttofileanAppeal
whenYouareunhappywitha decision that has been made by Us. At any time during the course of
the Complaint and Appeal process, You may choose to designate an Authorized Representative to
participate in the Complaint and Appeal process on Your behalf. Appointment of representatives is
completed in accordance with Ourprivacypolicies.
AComplaintisanoralexpressionofdissatisfaction.Complaintscaninvolvemanydifferentissues,including
butnotlimitedtothefollowing:
• Access-appointmentavailability
• Attitude
• Billingandfinancial
• QualityofPractitionerofficesite:physicalappearance,physicalaccessibilityofofficepracticesites
• Concernsrelatedtoequityofcareordiscrimination
• Unprofessionaltreatmentbyprofessionals
• Medicalrecordaccessanddocumentation
• Patientcareclinicaloutcomes
• Fraud,wasteorabuse
• Privacy/HIPAAviolations
WHATTODOIFYOUHAVEACOMPLAINT
ContactCustomerServiceatthetelephonenumbershownonYourIDcard.CustomerService
representativesareavailabletotakeyourcallduringregularbusinesshours,MondaythroughFriday.
AfterWereceiveYourComplaint,WewillnotifyYouofOurdecisionwithin30days.
APPEALSPROCESS
AnAppealisawrittenrequesttoreviewanydecisionregardinganyCompliantoranyAdverseBenefit
Determination. AnAdverseBenefitDeterminationmeansanyofthefollowing:
• AnydecisiontorescindthisContract,and
• Anydenial,reduction,orterminationof,orafailuretoprovideormakepayment(inwholeorin
part)foraBenefit,basedonanyofthefollowing:
o adeterminationofYourorYourDependent’seligibility,
o theapplicationofanyutilizationreview,
o adeterminationthattheitemorserviceisforExperimentalorInvestigational Treatment
o adeterminationthattheitemorservicesisnotMedicallyNecessaryorappropriate.
YouorYourAuthorizedRepresentativecanfileanAppealwithinthreeyearsofOurdecision
concerninganymatter.TofileaformalAppeal,YouorYourAuthorizedRepresentativeshouldwrite
downYourconcernsandmailyourwrittenAppeal(inanyform)alongwithcopiesofanysupporting
documentstous.Submityourwrittenappealto:
• Children’sCommunityHealthPlan
[P.O.Box1997,MS6280
Milwaukee,WI53201-1997]
WewillsendYoualetterwithinfivebusinessdaysnotifyingYouthattheAppealwasreceived. Our
acknowledgmentletterwilladviseYouof:
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COMPLAINTSANDAPPEALS
• Yourrighttosubmitwrittencomments,documentsorotherinformationregardingtheAppeal,
• Yourrighttobeassistedorrepresentedbyanotherpersonofyourchoice,
• YourrighttoappearbeforetheAppealsCommitteeinpersonorviateleconference,andthe
dateandtimeofthenextscheduledmeeting.Youwillreceiveatleast7calendarday’snotice
ofthemeeting.
• AvailabilityofinterpreterservicesduringtheAppealprocess,fornon-Englishspeaking
andhearingimpairedmembers.
• HowtocontactUsforschedulingortoprovideadditionalinformation.
Depending on the type of Appeal, either Our Appeals Committee or specialist will review the Appeal,
investigate and provide You with a decision within 30 calendar days of receiving the Appeal. If We are
unable to resolve the Appeal within 30 calendar days, You will be notified and receive an explanation
that the Appeal is not resolved and the time period will be extended another 14 calendar days.
Notificationwillincludewhentheresolutionmaybeexpectedandwhyadditionaltimeisneeded. The
totaltimeforresolutionwillbenomorethan45daysfromthedatetheAppealwasreceived.
WHATTODOIFYOURAPPEALREQUIRESIMMEDIATEACTION
ArequestforanurgentAppealwillbeconsiderediftheapplicationofthetimeperiodformakinganon-
urgentdetermination:
• couldseriouslyjeopardizeYourlifeorhealth orYourabilitytoregainmaximumfunction,basedon
aprudentlayperson’sjudgment,or
• intheopinionofapractitionerwithknowledgeofYourmedicalcondition,wouldsubjectYouto
severepainthatcannotbeadequatelymanagedwithoutthecareortreatmentthatisthe
subjectoftherequest.
TherequestforanurgentAppealdoesnothavetobeinwriting.UrgentAppealswillberesolvedwithin
72 hours after receipt, or sooner as needed to accommodate the urgency of the situation. You will
receivebothverbalandwrittennotificationofthedecision.
WHATTODOIFYOUDISAGREEWITHOURDECISION
YoumaytrytoresolveyourproblembytakingthestepsoutlinedaboveintheComplaintsand
Appealsprocess.YoumayalsocontacttheOfficeoftheCommissionerofInsurance,astateagency
whichenforcesWisconsin’sinsurancelaws,andfileaComplaint.YoucancontacttheOfficeofthe
CommissionerofInsurancebywritingto:
•
OfficeoftheCommissionerofInsurance
ComplaintsDepartment
P.O.Box7873
Madison,WI53707-7873
Youcancall(800)[email protected].
PleasenotethatOurdecisionisbasedonlyonwhetherornotBenefitsareavailableundertheContract.
Wedonotdeterminewhetherthependinghealthserviceisnecessaryorappropriate.Thatdecisionis
betweenyouandyourPractitioner.
EXTERNALREVIEWPROGRAM
WhenWehavedeniedanAppeal,YoumayhavetherighttohaveOurdecisionreviewedbyan
independentrevieworganizationexternaltoUs.
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COMPLAINTSANDAPPEALS
Youmayfileawrittenrequestforanexternalreviewwithinfourmonthsafterthedateofreceiptofthe
noticeofAdverseBenefitDeterminationorfinalinternalAdverseBenefitDetermination.Torequestan
externalreview,calltollfree[1-888-866-6205]torequestanexternalreviewrequestform.Faxthisform
to:{888-866-6190},ormailtheexternalreviewrequestformto:
• [MaximusFederalServices,
3750MonroeAve,Suite705
Pittsford,NY14534.]
TheinformationprovidedontherequestformwillbeusedtoobtaintherelevantdocumentsfromUs.
Youmayalsosubmitsupportinginformationanddocuments.Forexample:
• Documentstosupporttheclaim,suchasphysicians’letters,reports,bills,medicalrecords,and
explanationofbenefits(EOB)forms;
• LettersYousenttoUsabouttheissue;or
• LettersreceivedfromUsabouttheissue.
STANDARDREVIEW
Whentheexternalreviewexaminerreceivestheexternalreviewrequesttheexaminerwillreviewthe
informationprovidedbyUsandmayrequestadditionalinformation.Theexternalreviewexaminerwill
notifyYouinwritingifitdeterminesthatYouarenoteligibleforanexternalreview.
TheexternalreviewmaybeterminatedifWedecidetoreverseOurdecisionandprovidecoverageor
paymentafterreconsideration.WemustprovidewrittennoticetoYouandtheexaminerwithinone
businessdayaftermakingthedecisiontoreverse.
TheexaminermustprovidewrittennoticeofafinaldeterminationontheexternalreviewtoYouandUsas
expeditiouslyaspossible,butnolaterthan45calendardaysfromthedateofreceiptoftherequestfor
externalreview.
Thefinalexternalreviewdecisionnoticewillcontain:
• Adescriptionofthereasonfortherequestedexternalreviewwithsufficientinformationto
identifytheclaim;
• Thedatetheexaminerreceivedtheexternalreviewassignment;
• Referencestoevidenceordocumentationconsideredindecision;
• Discussionofthereasoningforthedecisionincludingrationaleandanyevidence-basedstandards
reliedon;
• Astatementthatthedecisionisbindingexcepttotheextentthatotherremediesmaybeavailable
underStateorFederallaw;
• Astatementthatjudicialreviewmaybeavailable;and
• Currentcontactinformationforanyapplicablehealthinsuranceconsumerassistanceor
ombudsman.
Theexaminermustmaintainrecordsofallclaimsandnoticesassociatedwiththeexternalreviewprocess
forsixyearsandmaketherecordsavailableforexaminationbyYouorUsuponrequest.Uponreceiptofa
finalexternalreviewdecisionreversingtheAdverseBenefitDeterminationorfinalinternalAdverseBenefit
DeterminationWemustimmediatelyprovidecoverageorpaymentfortheclaim.
EXPEDITEDREVIEW
Anexpeditedtimelineisfollowedincaseswheretheclaimmeetsthecriteriasetforthin45CFR147.136
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COMPLAINTSANDAPPEALS
(d)(2)(ii).TheexaminerwillnotifyYouorUsasexpeditiouslyaspossibleiftheexaminerdeterminesthat
Youarenoteligibleforexternalreview.
TheexternalreviewmaybeterminatedifWedecidetoreverseOurdecisionandprovidecoverageor
paymentafterreconsideration.WemustimmediatelyprovidenoticetoYouandtheexaminerafter
makingthedecisiontoreverse.Thisnoticemaybeoralbutmustbefollowedupwithwrittennotice
within48hours.
ThereviewershallmakeafinaldeterminationontheexternalreviewandcommunicateittoYouandUs
within72hoursfromthetimeofreceiptoftherequestorsoonerdependingonmedicalcircumstancesof
thecase.IfYouarenotifiedorally,thereviewerwillfollow-upwithwrittennoticewithin48hoursafter
deliveryoftheoralnotice.Theexaminer’sfinalexternalreviewdecisionandrecordsmaintenancemust
complywiththesamerequirementsasforfinalexternalreviewdecisionsinstandardexternalreview.
UponreceiptofafinalexternalreviewdecisionreversingtheAdverseBenefitDeterminationorfinal
internalAdverseBenefitDetermination,Wemustimmediatelyprovidecoverageorpaymentfortheclaim.
IfYouneedtechnicalassistancefromtheexternalrevieworganization,call{1-888-866-6205}.Youmay
leavemessagesandreceiveinstructionsonsubmittingexpeditedexternalreviewrequests.TTYfor
hearingimpaired,interpretersandtranslatedbrochuresareavailableuponrequest.
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HEALTHMANAGEMENTPROGRAMS
Children’sCommunityHealthPlan(CCHP)offersavarietyprogramsavailableatnoextracosts.Contact
Usformoreinformationandtoenroll.
CASEMANAGEMENT
Casemanagementisacollaborativeprocesswhichassesses,plans,implements,coordinates,monitors
andevaluatestheoptionsandservicestomeetanindividual’scomplexhealthneeds,using
communicationandavailableresourcestopromotequality,costeffectiveoutcomes.Casemanagement
servicesinclude:
•Comprehensiveassessments;
•Integratedgoalandcareplanning;
•Crisisintervention;
•Riskmanagement;
•Careandresourcecoordination;
•Educationaboutconditionordisease,includingself-management;
•MedicationReconciliation;
•Communitylinkageopportunities;and,
•Advocacythroughastrength-based,traumasensitiveapproach
ThiscollaborativecasemanagementprocessinvolvesintegratingwiththeservicesofothersintoYour
care,includingutilizationanddiseasemanagement.
DISEASEMANAGEMENT
DiseaseManagementprogramswithinCCHParedesignedtoimprovethehealthofindividualswith
specificchronicconditionsandtoreducehealthcareserviceuseandcostsassociatedwithavoidable
complications,suchasemergencyroomvisitsandhospitalizations.Weconsideranintegratedsystemof
intervention,measurementandrefinementofhealthcaredeliverydesignedtooptimizeclinicaland
economicoutcomeswithinthesespecificallydefinedpopulations. CoveredPersonswithDepression
and/orAsthmaareprovidedanintroductoryletterexplaininghowtobecomeeligibletoparticipate,
howtousetheservices,andhowtooptoutoftheprogram,ifdesired.
ForCoveredPersonswhowouldlikehelpmanaginganyconcernsrelatedtotheirhealth,pleasecall[1-
844-450-1926]toreachtheClinicalServicesstaffformoreinformation.
HEALTHYMOM,HEALTHYBABY
WehaveaprogramcalledHealthyMom,HealthyBabythatisfreeforallCoveredPersons.Itisa
programthathelpspregnantwomengetthesupportandservicesneededtohaveahealthybaby.
Servicesareprovidedbysocialworkersornurseswhohaveaspecialbackgroundforprovidingservices
forpregnantmomsandfamilies. WeprovidethisserviceatYourhome,aplacethatYoupreferorby
phone.Otherservicesincludebreastfeedingsupportandhighriskfamilycasemanagement.Wewill
behappytogiveYoumoreinformationandsetYouupwithanappointmentwithoneofourcase
managers. WewillsendYoua[$10]giftcardwhenYouletusknowYouarepregnant. Pleasecall[1844-450-1926]formoreinformation.
CHILDREN’SCOMMUNITYHEALTHPLANNURSELINE-CCHPonCall
YourPrimaryCareProvidercanalwaysbecalledtoanswermedicalquestionsforYou.Youmayalsouse
CCHPonCallwhichisoursystemforansweringYourhealthcarequestions.
WhenshouldIuseCCHPonCall?
•BeforeYougototheemergencyroom.Iftheemergencyislifethreatening,call911.
•Foranygeneralhealthquestionsorconcerns.
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HEALTHMANAGEMENTPROGRAMS
•IfYourchildhasafever.
•IfYourchildsprainsanankle.
•IfYouneedhelpdecidingwheretogoforhelp.
•IfYouhaveaskinirritationorrash.
•IfYourchildhasascrapeorcut.
•AnytimeYouhaveaquestionaboutwheretogoforYourhealthcare.
WhyshouldIuseCCHPonCall?
•ThenursescanhelpYougetthecarethatisrightforYouandYourfamily.
•TheycanadviseYouonthepropertreatmenttokeepYouandYourfamilyhealthy.
Whowillanswermyhealthcarequestions?
•TrainednursesanswerallofYourquestions.
•TheymayaskYoutodescribethesymptomsorproblemsYouarehaving.
•TheywillhelpYoudecidehowtogetthebesttreatmentpossibleforYouandYourfamily.
•TheycanhelpYouunderstandhowtoaccesscarethroughChildren’sCommunityHealthPlan.
Wehavenursesonduty24hoursaday,sevendaysaweektohelpanswerYourquestions.Simplycall[1-
877-257-5861].Thisisafreephonecall.
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