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Suburban Plan For School District Of Philadelphia SPD

Suburban Plan For School District Of Philadelphia SPD

The SPD (Summary Plan Description) is the booklet which describes the rules of your plan of benefits, including eligibility, coverage, how to file claims and co-pays. Check below to find the section of the SPD you are interested in.


Summary of Material Modifications(SMM) - 2013-05-22


The attached Summary of Benefits and Coverage describes the current Hospital and Medical and Mental Health and Substance Abuse benefits (click here)

Appeals and Claims Reviewers (click here)
Important Notice

This booklet is the Summary Plan Description ("SPD") of the plan of benefits ("the Plan") of the Building Service 32BJ Health Fund ("the Fund") with regard to the Suburban Plan for the School District of Philadelphia. Your rights to benefits can only be determined by this SPD, as interpreted by official action of the Board of Trustees ("the Board"). You should refer to this booklet when you need information about your Plan benefits. In addition, the Board reserves the right, in its sole and absolute discretion, to amend the Plan at any time.

  • Save this booklet – put it in a safe place. If you lose a copy, you can ask Member Services for another or obtain it from www.seiu32bj.org.
  • If you change your name or address – notify Member Services immediately so your records are up-to-date.
  • Words that appear in boldface print are defined in the Glossary.
  • Throughout this booklet, the words "you" and "your" refer to participants whose employment makes them eligible for Plan benefits. The word "dependent" refers to a family member of a participant who is eligible for Plan benefits. In the sections describing the benefits payable to participants and dependents, the words "you" and "your" may also be used to refer to the patient.
  • This booklet describes the provisions of the Plan in effect as of May 1, 2010 unless specified otherwise. If you are a retiree and are eligible for Plan benefits, you are eligible for the current Plan benefits, not the Plan benefits in effect at the time you stopped working.
  • In the event there is any conflict between the terms and conditions for Plan benefits as set forth in this booklet and any oral advice you receive from a Building Service 32BJ Benefit Funds employee or union representative, the terms and conditions set forth in this booklet shall control.
  • The level of contributions provided for in your collective bargaining agreement or participation agreement determines the Plan for which you are eligible.

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Eligibility And Participation

When You Are Eligible

Eligibility for benefits from the Plan depends upon the particular agreement that covers your work.

Your employer will be required to begin making contributions to the Plan on your behalf when you have completed six months of covered employment. Days of illness, pregnancy or injury count toward the six months waiting period. When you have completed the six months waiting period, you and your eligible dependents become eligible for the benefits described in this booklet on your 181st day of covered employment.

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When You Are No Longer Eligible

Your eligibility for the Plan ends:

  • at the end of the 30th day after you no longer regularly work in covered employment, subject to COBRA rights (see pages 60-63)
  • on the date when your employer terminates its participation in the Plan, or
  • on the date the Plan is terminated.

In addition, the Board reserves the right, in its sole discretion, to terminate eligibility if your employer becomes seriously delinquent in its contributions to the Fund.

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If You Come Back To Work

ALERT: 5/22/13 NEW Click here for important benefit changes>>

If your employment ends after your eligibility commenced and you return to covered employment (with the same contributing employer or a different contributing employer):

  • within 90 days, your Plan participation starts again on your first day back at work, or
  • more than 90 days later, you would have to complete 180 consecutive days of covered employment with the same employer before participation resumes.

As long as you are eligible, your dependents are eligible, provided they meet the definition of"dependent" under the Plan (see"Dependent Eligibility" on pages 10-14).

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Extension of Health Benefits

Health coverage may be continued while you are not working in the following circumstances:

COBRA

Under a Federal law called the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), group health plans are required to offer temporary continuation of health coverage, on an employee-pay-all basis, in certain situations when coverage would otherwise end."Health coverage" includes the Plan's hospital, medical and behavioral health, and substance abuse coverage. See pages 60-63 for more information about COBRA.

Fund-paid COBRA

If all eligibility requirements are met, the Fund will pay for COBRA coverage in the following situations: disability and arbitration. All periods of Fund-paid COBRA will count toward the period in which you are entitled to continuing coverage under COBRA. Coverage for Fund-paid COBRA includes the Plan's hospital, medical and behavioral health, and substance abuse coverage.

To receive this extended coverage, you must complete the COBRA Continuation of Coverage Election Form you receive in the mail. If you fail to timely return the Election Form, you may lose eligibility for continuation of coverage under Fund-paid COBRA. The completed Election Form along with all required documents (e.g., proof of disability) must be returned to:

COBRA Department
Building Service 32BJ Benefit Funds
101 Avenue of the Americas
New York, NY 10013-1991

Disability

You may continue to be eligible for up to 30 months of health coverage (up to 12 months paid by the School District of Philadelphia and up to 18 additional months through Fund-paid COBRA), provided you enroll for coverage, are unable to work and are receiving (or are approved to receive) one of the following disability benefits:

  • short-term disability, or
  • Workers' Compensation.

When any of the following events occur, your extended coverage will end:

  • if you elect to discontinue coverage
  • if you work at any job
  • on the date your disability benefit is terminated because the Fund has determined that you are no longer totally disabled
  • 30 months after you stopped working due to a disability
  • when your Workers' Compensation or short-term disability ends
  • when you receive the maximum benefits under short-term disability or Workers' Compensation, or
  • when you become eligible for Medicare as your primary insurer.
  • If you die while receiving extended health coverage, your dependents' eligibility will end 30 days after the date of your death.

    To receive Fund-paid COBRA, you must apply and submit proof of disability no later than 60 days after the date coverage would have been lost (12 months after you stopped working due to a disability). You apply by completing the COBRA Continuation of Coverage Election Form which is mailed to you. In addition, you can obtain a copy of this form from Member Services. The Plan reserves the right to require proof of your continued disability from time to time. This extension of coverage will count toward the period in which you are entitled to continuing coverage under COBRA. See pages 60-63 for COBRA information.

    Arbitration

    If you are discharged* and the Union takes your grievance to arbitration seeking reinstatement to your job, your health coverage will be extended for up to six months or until your arbitration is decided, whichever occurs first (see Fund-paid COBRA on page 7). This extension of coverage will count toward the period in which you are entitled to continuing coverage under COBRA.

    * Indefinite suspensions or suspensions pending discharge are treated the same as discharges.

    FMLA

    You may be entitled to take up to a 26-week leave of absence from your job under the Family and Medical Leave Act (FMLA). You may be able to continue health coverage during an FMLA leave. See pages 58-59, and 61, for more information.

    Military Leave

    If you are on active military duty, you have certain rights under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) provided you enroll for continuation of health coverage. See pages 59-60 for more information. This extension of coverage will count toward the period in which you are entitled to continuing coverage under COBRA.

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    Dependent Eligibility

    ALERT: 5/22/13 NEW Click here for important benefit changes>>

    If your collective bargaining agreement or participation agreement provides for dependent coverage, eligible dependents under the Plan are described below:


    Dependency

    Age Limitation

    Requirements

    Lawful Spouse None The person to whom you are legally married under the laws of the place where you live (if you are legally separated or divorced, your spouse is not covered).
    Domestic Partner   You and your same-gender domestic partner (unless the laws of the place where you live provide for same-gender marriage):
    • Have a civil union certificate from a state in the U.S. or province in Canada where same-gender civil unions are valid, or
    • Are two individuals 18 years or older of the same-gender who:
      • - Have been living together for at least 12 months; and
      • - Are not married to anyone else, and are not related by blood in a manner that would bar marriage under the law; and
      • - Are financially interdependent, and can show proof of such; and
      • - Have a close and committed personal relationship and have not been registered as members of another domestic partnership within the last 12 months.

    In order to establish eligibility for these benefits, you and your domestic partner will need to provide:

    • A civil union certificate from a state in the U.S. or province in Canada where same-gender civil unions are valid, or
    • If neither marriage nor civil union certificates are available, affidavits attesting to your relationship, plus a domestic partner registration under state or local law (if permitted where you live), and proof of financial interdependence.

    You are required to provide the highest level of certificate available in the jurisdiction where you reside.

    Contact Member Services for an application or general information. There may be significant tax consequences for covering your domestic partner or same-gender spouse. Contact a tax advisor for tax advice.

    If you lose coverage due to a qualifying event, you and your domestic partner may elect to continue coverage on a self-pay basis through COBRA. Domestic partners will not have an independent right to COBRA continuation coverage unless the qualifying event is the participant's death.

    Children (except disabled children) Until end of calendar year in which dependent child reaches age 19 (or age 23, if a full-time student in an accredited high school, college, university or trade school)

    The child:

    • is not married
    • has the same principal address as the participant*, or as required under the terms of a"QMCSO" (see page 64) and
    • is dependent on the participant for over one-half of his or her annual support and is claimed as a dependent on your tax return*

    AND

    is one of the following:

    • your biological child
    • your adopted** child or one placed with you in anticipation of adoption
    • your stepchild: this includes your spouse's biological or adopted child
    • your domestic partner's biological or adopted child
    • a foster child ONLY if you have adopted** the child or applied for adoption
    • your grandchild, niece or nephew ONLY if you are the legal guardian*** and the child is dependent on you and only you for all support and maintenance; if application for legal guardianship is pending, you must provide documentation that papers are filed and provide proof when legal process is complete.

    Effective July 1, 2010, if a dependent child, who is enrolled in Fund coverage under this section, is on a medically necessary leave of absence from post- secondary school because of a serious injury or illness, coverage under this Plan will be extended, free of charge to the dependent during his/her leave of absence, until the earlier of (1) the one year anniversary of the date on which his/her leave of absence began, or (2) the date on which the dependent child's coverage under the Plan would otherwise terminate. To be eligible for this extended coverage, the participant must provide the Fund with written certification from the dependent child's treating physician that his/her leave of absence from school is medically necessary and is as a result of a serious illness or injury. The extended coverage commences on the date such certification is received by the Fund, but will be retroactive to the date on which his/ her leave of absence began. Extended coverage under this section is concurrent with, and not in addition to, coverage under COBRA (see pages 60-63). This means that if the dependent child receives one-year of extended coverage under this section and, after the expiration of this one-year period, he/she is not eligible for active Fund coverage (e.g., he/she did not return to school, has attained age 23 or has gotten married), the child can elect to continue coverage under COBRA, but only for a maximum of 24 months.

    Children (disabled) None

    The child:

    • is totally and permanently disabled
    • became disabled while, or before becoming, an eligible dependent, and
    • meets all of the requirements listed above for a depen- dent child except age.

    You must apply for a disabled child's dependent coverage extension and provide proof of the child's total and permanent disability no later than 60 days after the date the child would have otherwise lost eligibility, and you must remain covered under the Plan. You will be notified by the Fund if your adult disabled child is found eligible for continuing coverage. You must enroll your adult disabled child within 60 days of receiving confirmation of your adult child's eligibility. Failure to enroll at this time means your disabled adult child loses his or her special eligibility. If your child becomes eligible for extended coverage as a result of disability, you will be required to pay a monthly premium to cover part of the coverage cost. Contact Member Services for details.

    Note that:
    • A dependent must live in the United States, Canada or Mexico unless he or she is a United States citizen.
    • A child is not considered a dependent under the Plan if he or she is in the military or similar forces of any country.

    * If you are legally separated or divorced, then your child may live with and/or be the tax dependent of the legally separated or divorced spouse. If you were never married to your child's other parent, then the child may live with the other parent but must be your tax dependent.

    ** Your adopted dependent child will be covered from the date that child is adopted or"placed for adoption" with you, whichever is earlier (but not before you become eligible), if you enroll the child within 30 days after the earlier of placement or adoption (see"Your Notification Responsibility" on page 14). A child is placed for adoption with you on the date you first become legally obligated to provide full or partial support of the child whom you plan to adopt. However, if a child is placed for adoption with you, but the adoption does not become final, that child's coverage will end as of the date you no longer have a legal obligation to support that child. If you adopt a newborn child, the child is covered from birth as long as you take custody immediately after the child is released from the hospital and you file an adoption petition with the appropriate state authorities within 30 days after the infant's birth. However, adopted newborns will not be covered from birth if one of the child's biological parents covers the newborn's initial hospital stay, a notice revoking the adoption has been filed or a biological parent revokes consent to the adoption.

    *** Legal guardian(ship) includes legal custodian(ship).

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    When Your Dependents Are No Longer Eligible

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    Your dependents remain eligible for as long as you remain eligible except for the following:

    • Your spouse's eligibility ends 30 days after legal separation or divorce. Your domestic partner's eligibility ends 30 days after the requirements for domestic partnership on page 10 are no longer satisfied.
    • Your child's eligibility ends when your child marries or no longer satisfies the rules regarding residence or financial dependency that are described on pages 11-12, or
    • - if not in school, at the end of the calendar year in which the child reaches age 19, or
      - if in school,
      • - 30 days after the child's graduation from school, or, if earlier,
      • - 30 days after the date the child leaves school, or, if earlier,
      • - at the end of the calendar year in which the child reaches age 23.
    • Eligibility of a spouse, a domestic partner, and dependent children ends 30 days after your death.

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    How to Enroll

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    Coverage for dependents under the Plan is not automatic.

    Enroll your dependents as soon as they become eligible. Please see"Dependent Eligibility" on pages 10-14 to determine when your dependents are eligible. If at the time you become eligible under the Plan your dependents are eligible for benefits, you must complete the"Dependent Information" section of the Enrollment Form. You will be required to submit documents proving dependent status including a marriage certificate (for your spouse), birth certificates and, if applicable, proof of full-time student status (for your children). In most cases, your dependent's coverage will begin on the date he or she was first eligible. However, if you do not enroll your dependents that are eligible when you first complete the Enrollment Form, your dependent's coverage will not begin until the date you notify the Fund. No benefits will be paid until you provide the Fund with your eligible dependent's information and supporting documentation. After your coverage under the Plan begins, if you have a change in family status (e.g., get married, adopt a child) or wish to change existing dependent coverage for any reason, you must complete the appropriate form. Special rules apply regarding the effective date of your new dependent's coverage. Please see"Your Notification Responsibility" on page 14 for further details.

    Dependent claims for eligible expenses will be paid only after the Fund has received your completed Enrollment Form and supporting documentation. If your forms are not completely or accurately filled out, or if the Fund is missing requested documentation, any benefits payable will be delayed. The Fund may periodically require proof of continued eligibility for you or a dependent. Failure to provide such information could result in a loss of coverage.

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    Your Notification Responsibility

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    If, after your coverage under the Plan becomes effective, there is any change in your family status (e.g., marriage, legal separation, divorce, birth or adoption of a child), it is your responsibility to notify the Fund immediately of such change and complete the appropriate form. If you notify the Fund within 30 days of marriage or birth or adoption of a child, coverage for your new spouse or child will begin as of the date of marriage or date of birth or adoption. If you do not notify the Fund within 30 days, coverage for your new spouse or child will begin as of the date you notify the Fund. No benefits will be paid until you provide the Fund with the necessary supporting documentation. Also, be sure to notify the Fund if your child is between age 19 and 23 and graduates or otherwise leaves school, or if your child marries or no longer satisfies the rules regarding residence or financial dependency that are described on pages 11-12.

    If, after your coverage under the Plan becomes effective, your dependent(s) lose eligibility for Medicaid or Children's Health Insurance Program (CHIP) or become eligible for a state subsidy for enrollment in the Plan under Medicaid or CHIP, and you would like to enroll them in the Plan, it is your responsibility to notify the Fund immediately of such change and complete the appropriate form. If you notify the Fund within 60 days of the loss of Medicaid/CHIP or of your dependent's becoming eligible for the state subsidy, coverage for your dependent(s) will begin as of the date your dependent(s) lost eligibility for Medicaid/CHIP or the date they became eligible for the subsidy. If you do not notify the Fund within 60 days, coverage for your dependent(s) will begin as of the date you notify the Funds. Failure to notify the Funds of your dependents' loss of eligibility for Medicaid/CHIP or becoming eligible for the state subsidy could lead to a delay or denial in the payment of health benefits or the loss of a right to elect health continuation under COBRA.

    Failure to notify the Fund of a change in family status could lead to a delay or denial in the payment of health benefits or the loss of a right to elect health continuation under COBRA. In addition, knowingly claiming benefits for someone who is not eligible is considered fraud and could subject you to criminal prosecution.

       
    What Benefits Are Provided

    The Fund provides hospital and medical, behavioral health and substance abuse benefits (only for pensioners under the Building Service 32BJ Pension Fund). Each of these benefits is described in the sections that follow.

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    Hospital And Medical Benefits

    Overview of Eligible Expenses

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    Provision

    in-network

    out-of-network

    How you can receive treatment Go to any network provider Go to any licensed/certified provider (unless out-of-network care is specifically excluded). See pages 22-27
    Basis for reimbursement All in-network reimbursements are based on the allowed amount for Medically Necessary eligible expenses and subject to pre-certification and co-payments where required; network providers have agreed to accept the allowed amount as payment in full. All out-of-network reimbursements are based on the allowed amount for Medically Necessary eligible expenses and subject to the annual deductible, co-insurance and pre-certification where required. out-of-network providers may or may not accept Empire BlueCross BlueShield payment as payment in full (excluding deductibles and co-insurance); if they do not, you are responsible for paying any excess amount.
    Annual deductible
    - individual
    - family

    Not applicable
    Not applicable

    $250
    $500
    Co-payments
    (where applicable)
    $15 per visit
    $50/emergency room visit
    Not applicable
    $50/emergency room visit
    Co-insurance
    (where applicable)
    Plan pays 100% after the co-payment Plan pays 70% of the allowed amount after the deductible
    Annual co-insurance maximums (excluding deductibles)
    - individual
    - family
    Not applicable
    Not applicable
    $750
    $1,500
    Lifetime maximum benefit No limit $1,000,000

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    About the Empire Networks

    ALERT: 5/22/13 NEW Click here for important benefit changes>>

    The Plan provides hospital and medical benefits through Empire BlueCross BlueShield ("Empire"). The Plan offers the BlueCross BlueCard Plan. This network includes doctors and hospitals.

    When you use a network provider, you will have minimal or no cost for services.

    You are also covered when seeing out-of-network doctors, but you will incur substantial charges since the Plan pays 70% of the allowed amount, which is generally less than the amount you are charged. So when you go out-of-network, you pay 30% plus the difference between what you are actually charged and what the Plan recognizes as the allowed amount for that particular service, treatment or supply.

    Empire ID Card. This card gives you access to thousands of doctors, surgeons, hospitals and other health care facilities in the network. It also gives you 24-hour phone access to a registered nurse who can help you with your health care decisions. Plus, your Empire ID card can get you discounts on certain non-covered services, such as laser vision correction, health club memberships and Weight Watchers programs.

    Nurses Healthline. This is round-the-clock information free to Empire members. When you call, you can either speak to a registered nurse or select from over 1,100 audiotaped messages in English or Spanish on a wide variety of topics. If you do not speak English or Spanish, interpreters are available through the AT&T Language Line. You may find it helpful to speak to a registered nurse when you need help assessing symptoms, deciding whether a trip to the emergency room is necessary or understanding a medical condition, procedure, prescription or diagnosis. You can reach the Nurses Healthline at 1-877-825-5276.

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    When You Go in-network

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    When you use an in-network provider, your expenses are covered at the highest level. In addition, there are no deductibles or co-insurance to pay, and no claims to file or track.

    in-network benefits apply only to services and supplies that are both covered by the Plan and provided or authorized by a network provider. The network provider will assess your medical needs and advise you on appropriate care, as well as take care of any necessary tests, pre-certifications or hospital admissions. When you use a doctor, hospital or other provider in-network, the Plan generally pays 100% for most charges, including hospitalization. You will not have to satisfy a deductible - you will pay only a $15 co-payment for doctor visits and certain other services and supplies, such as outpatient physical therapy or chiropractic care.

    You should always check with your network provider to be sure that any referrals to other doctors or for diagnostic tests are also in-network.

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    When You Go out-of-network

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    Care that is not provided by a network provider is considered out- of-network care and, as such, reimbursed at a lower level. If you use out-of-network providers, you must first satisfy the annual deductible before being reimbursed at 70% of the allowed amount. Amounts above the allowed amount are not eligible for reimbursement and are your responsibility to pay, in addition to any deductibles and required co-insurance. If you use an out-of-network provider, ask your provider if he or she will accept Empire's payment as payment in full (excluding your deductible or co-insurance requirements). While many providers will tell you that they take"32BJ" or"Empire" coverage, they may not accept Plan coverage as payment in full. Then they will bill you directly for charges that are over the Plan's allowed amount. In addition to the 30% you pay, you will then be responsible for the excess charges.

    Annual deductible. $250 individual or $500 family, provided one covered individual in a family has met the individual deductible.

    Common accident deductible. If two or more family members are injured in the same accident and require medical care, the family must meet only one individual deductible.

    Expenses that do not count toward the deductible:

    • in-network co-payments
    • charges that exceed the allowed amount for eligible out-of-network expenses
    • amounts that you pay because you failed to pre-certify a hospital stay or meet any other similar pre-certification requirements
    • charges excluded or limited by the Plan (see pages 28-33).

    Co-insurance. Once the annual deductible is met, the Plan pays 70% of the allowed amount for eligible out-of-network expenses. You pay the remaining 30%, which is your co-insurance. You also pay any amounts over the allowed amount.

    Annual co-insurance maximum. The Plan limits the co-insurance each patient has to pay in a given calendar year to $750. The family limit is $1,500. Once one person in the family has paid $750 in co-insurance and the rest of the covered family members combined have paid $750 more in co-insurance (for a total of $1,500), you have met the family co-insurance maximum for that year. Any eligible expenses submitted for reimbursement after the annual co-insurance maximum is reached are paid at 100% of the allowed amount. You still have to pay any charge above the allowed amount.

    Expenses that do not count toward the co-insurance maximum. The following expenses are not applied toward the out-of-network annual co-insurance maximum:

    • in-network co-payments deductibles
    • charges that exceed the allowed amount for eligible out-of-network expenses
    • amounts that you pay because you failed to pre-certify a hospital stay or meet any other similar pre-certification requirements
    • charges excluded or limited by the Plan (see pages 28-33).

    If you stay with your choice of an out-of-network provider, then you should fully understand that your out-of-network claim will be paid as follows:

    You must first satisfy the annual deductible before being reimbursed at 70% of the allowed amount. In most instances, the allowed amount is significantly less than the amount charged by the non-participating provider. Any balance bills that you receive are your responsibility and are not covered by the Plan because your provider is not in the Empire network.

    Your Explanation of Benefits will show the maximum amount the provider can charge you. This will be reflected in the box labeled"Your Total Responsibility To Your Provider".

    In addition to the 30% you pay, you are also responsible for the excess charges that the provider bills for. Charges above the allowed amount are not eligible for reimbursement and are your responsibility to pay, in addition to any deductibles and required co-insurance. The following is an example of what out-of-network care when using a non-participating provider can cost you.

    • The non-participating surgeon's charge for total knee replacement surgery is $5,000. The allowed amount is $1,310. After you pay your $250 deductible and the Plan pays the applicable 70% co-insurance of the allowed amount, the balance due to the physician would be $4,333 and would be your responsibility to pay. If you had already satisfied your deductible in this example, then your balance due to the physician would be $4,083. In either case, using a non-participating provider will cost you a lot.

    While many providers will tell you that they take"32BJ" or"Empire BlueCross" coverage, they may not accept Plan coverage as payment in full. Then they will bill you directly for charges that are over the Plan's allowed amount. You should ask your provider if he or she would accept Empire's payment as payment in full (excluding your deductible or co-insurance requirements). If your provider agrees to accept Empire's payment as payment in full, it is best to get their agreement in writing.

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    Coverage When You Are Away from Home

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    There are thousands of BlueCard network providers in every state and many foreign countries. For the name of a nearby provider, call Member Services or check the Empire BlueCross web site"Provider Search".

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    Benefit Maximums

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    For in-network care, there is no lifetime limit on benefits payable. For out-of-network care, there is a $1,000,000 per person lifetime maximum for all hospital and medical benefits. There are also limits on how much (and how often) the Plan will pay for certain expenses, even when they are covered. If there are limits on a particular expense, those limits will be indicated under"Covered Services." (See pages 22-27.)

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    Conditions for Hospital and Medical Expense Reimbursement

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    • Charges must be for Medically Necessary care. The Plan will pay benefits only for services, supplies and equipment that the Plan considers to be Medically Necessary.
    • Charges must be less than or equal to the allowed amount. The Plan will pay benefits only up to the allowed amount.
    • Charges must be incurred while the patient is covered. The Plan will not reimburse any expenses incurred by a person while the person is not covered under the Plan.

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    Pre-Certification

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    When you use a network provider, the provider will do the pre- certification for you.

    When you use an out-of-network provider, it is your responsibility to have the required services pre-certified. This means that you have to contact the Fund's Health Services Program as shown on page 21, or make sure that your provider has done so. Failure to pre-certify will result in a financial penalty, which you will be responsible for paying.

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    Pre-Certification for Medical/Hospital

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    The following services must be pre-certified

    Call 1-866-230-3225
    24 hours a day, seven days a week.

    Type of Care When You Must Call

    Outpatient:

    • Air ambulance9 (non-emergency)
    • Speech, occupational and vision therapy
    • MRI or MRA exams
    • PET, CAT and nuclear imaging studies
    • Physical therapy
    • Prosthetics/orthotics or durable medical equipment (rental or purchase)

    As soon as possible before you receive care

    • Surgical procedures

    Two weeks before you receive surgery (inpatient and ambulatory) or as soon as care is scheduled

    Inpatient:
    • Scheduled hospital admissions
    • Admissions to skilled nursing or rehabilitation facilities
    Two weeks before you receive care or as soon as care is scheduled
    • Maternity admissions
    • Emergency admissions
    Within 48 hours after delivery or admission
    • Maternity admissions lasting longer than two days (or four days for cesarean delivery)
    • Ongoing hospitalization

    Within 48 hours after delivery or admission

    • Maternity admissions lasting longer than two days (or four days for cesarean delivery)
    • Ongoing hospitalization

    As soon as you know care is lasting longer than originally planned

    How pre-certification works. Empire's Medical Management Program will review the proposed care to certify the length of stay or number of visits (as applicable) and will approve or deny coverage for the procedure based on medical necessity. They will then send you a written statement of approval or denial within three business days after they have received all necessary information. In urgent care situations, Empire's Medical Management Program will make its decision within 72 hours after they have received all necessary information (for more information, see pages 44-47).

    If you do not pre-certify the care (except for outpatient maternity) listed above within the required time frames, benefit payments will be reduced by 50%, up to a maximum $250 reduction for each admission, treatment or procedure. If the Plan determines that the admission or procedure was not Medically Necessary, no benefits are payable.

    To pre-certify behavioral or substance abuse treatment, you must go through our Behavioral Health and Substance Abuse Services. See pages 33-40 for more information.

    The Health Services Program's Case Management staff can help you and your family explore your options and make the right treatment choices when you are facing a chronic or complicated illness or injury, such as cancer, heart disease, diabetes, or spinal cord and other traumatic injuries.

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    Covered Services

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    The following tables show different types of health care expenses and how they are covered in-network versus out-of-network.

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    In the Hospital1 and Outpatient Treatment Centers*

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    Benefit What You Pay
      In-network Out-of-network

    Semi-private room and board (for obstetrical care, hospital stays are covered for at least 48 hours following normal delivery, or at least 96 hours following cesarean section)

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    In-hospital services of licensed
    doctors and surgeons

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Surgery (inpatient or outpatient2) and care related to surgery (including operating and recovery rooms)

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Bariatric Surgery is only covered at facilities accredited by the American College of Surgeons (effective 1/1/09)

    Plan pays 100%

    Not Covered

    Anesthesia and oxygen

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Blood and blood transfusions

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Cardiac Care Unit (CCU) and Intensive Care Unit (ICU)

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Chemotherapy and radiation therapy

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Kidney dialysis3

    Plan pays 100%

    Not covered for treatment started after 4/5/07.

    Pre-surgical testing

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Skilled nursing care facility4*
    Benefits are payable for up to 60 days per year

    Plan pays 100%

    Not Covered

    Hospice care5 facility
    Benefits are payable for up to 210 days per lifetime (includes up to 12 hours a day of intermittent nursing care by an RN or LPN)

    Plan pays 100%

    Not Covered

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    Home Health Care6

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    Home health care visits

    Benefits are payable for up to 200 visits per year

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Home infusion therapy7

    Plan pays 100%

    Not Covered

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    Emergency Care

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    Emergency room8

    (no benefit if condition is not emergency)

    Plan pays 100% after $50 co-payment (waived if admitted from emergency room to hospital within 24 hours)

    If you call the Nurses Healthline (1-877-825-5276) and are directed to go to the emergency room, the Health Fund will reimburse your $50 co-payment. Call Member Services for reimbursement.

    Office visits

    $15 co-payment per visit

    Plan pays 70% of the allowed amount after the deductible

    Ambulance Services9

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    * Pre-certification required.

    See footnotes 4-9 on pages 77-79.

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    Care in the Doctor's Office

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    Benefit What You Pay
      In-network Out-of-network

    Office visits (including surgery2 in the office)

    $15 co-payment per visit

    Plan pays 70% of the allowed amount after the deductible

    Specialist visits

    $15 co-payment per visit

    Plan pays 70% of the allowed amount after the deductible

    Chiropractic visits
    10 visit maximum per year

    $15 co-payment per visit

    Plan pays 70% of the allowed amount after the deductible

    Second surgical opinion10

    $15 co-payment per visit

    Plan pays 70% of the allowed amount after the deductible

    Diabetes education and
    management11

    $15 co-payment per visit

    Plan pays 70% of the allowed amount after the deductible

    Allergy care:

    • Testing
    • Treatment

    $1,500 annual benefit maximum for testing/treatment combined

    $15 co-payment per visit

    Plan pays 70% of the allowed amount after the deductible

    Dermatology care:
    No maximum for the treatment
    of skin cancer; $1,000 annual
    benefit maximum for other
    conditions

    $15 co-payment per visit

    Plan pays 70% of the allowed amount after the deductible

    Diagnostic procedures:

    • X-rays and other imaging
    • MRIs/MRAs*
    • All lab tests

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Chemotherapy and radiation
    therapy

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Hearing exams (only when
    medically necessary)

    Plan pays 100%

    Plan pays 70% of the allowed amount after the deductible

    Podiatric care, including routine foot care (care of corns, bunions, calluses, toenails, flat feet, fallen arches, weak feet and chronic foot strain, and treatment of symptomatic complaints of the feet), but excluding routine orthotics

    $15 co-payment per visit

    Plan pays 70% of the allowed amount after the deductible

    * Pre-certification required.

    See footnote 2 on pages 76–77. See footnote 10 and 11 on page 79.

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    Preventive Medical Care

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    Benefit What You Pay
      In-network Out-of-network

    Annual physical exam12 including the necessary diagnostic screening tests based on the patient's age, sex and health risk factors

    $15 co-payment per visit

    Plan pays 70% of the allowed amount after the deductible

    Well-woman care

    • Office visits
      - An annual gynecological exam, including Pap smear, may be performed by an obstetrician/gynecologist or the patient's Primary Care Physician

    $15 co-payment per visit

    Plan pays 70% of the allowed
    amount after the deductible

    • Contraceptive Devices (IUDs and Diaphrams)

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible

    • Mammogram
      - for women age 35-39, one baseline test is covered*
      - for women age 40 and older, test covered once per year

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible

    Well-child care13 (including immunizations) subject to the following frequency limitations:
    - birth to age 1: 7 visits
    - age 1 through age 4: 6 visits
    - age 5 through age 11: 7 visits
    - age 12 through age 17: 6 visits
    - age 18 through age 23: 2 visits

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible

    * Coverage of mammograms regardless of age for covered persons with a past history of cancer or who have a first degree relative (mother, sister, child) with a prior history of breast cancer, upon the recommendation of a physician.

    See footnotes 12 and 13 on pages 79-80.

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    Pregnancy and Maternity Care

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    Benefit What You Pay
      in-network out-of-network

    Office visits for prenatal and
    postnatal care from a licensed
    doctor or certified midwife14,
    including diagnostic procedures

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible

    Newborn in-hospital nursery,
    home care

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible

    Obstetrical care*15 (in hospital,
    home or birthing center)

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible.
    No coverage for a nonparticipating
    birthing center.

    A home health care visit (if
    the mother leaves the hospital
    before the 48- or 96-hour period
    indicated under hospital benefits)

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible

    Circumcision of newborn males

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible

    * Pre-certification required.

    See footnotes 14 and 15 on page 80.

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    Physical, Occupational, Speech or Vision Therapy (including rehabilitation)16

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    Benefit What You Pay
      in-network out-of-network

    Inpatient Services*

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible

    Outpatient Services*

    Benefits are payable for up to 30 visits a year

    $15 co-payment
    per visit

    Not Covered

    Durable Medical Equipment and Supplies17

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    Durable medical equipment*
    (such as wheelchairs and hospital beds)

    Plan pays 100%

    Not Covered

    Prosthetics/orthotics* (orthotics are covered only for non-routine foot orthotics - limited to one pair per year)

    Plan pays 100%

    Not Covered

    Medical supplies (such as catheters and syringes)

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible

    Nutritional supplements18 that require a prescription (formulas and modified solid-food products)

    $2,500 maximum benefit in any 12-consecutive month period

    Plan pays 100%

    Plan pays 70% of the allowed
    amount after the deductible

    Hearing Aids - Benefits are payable for one hearing aid per ear per lifetime

    Plan pays 100%

    up to $550 per hearing aid

    * Pre-certification required.

    See footnotes 16, 17 and 18 on pages 80-81.

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    Excluded Hospital and Medical Expenses

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    The following expenses are not covered under the hospital or medical coverage and might be covered under your behavioral health and substance abuse benefits.

    • expenses incurred before the patient's coverage began or after the patient's coverage ended
    • treatment that is not Medically Necessary
    • cosmetic treatment19
    • technology, treatments, procedures, drugs, biological products or medical devices that in Empire's judgment are experimental, investigative, obsolete or ineffective20. Also excluded is any hospitalization in connection with experimental or investigational treatments.
    • expenses for the diagnosis or treatment of infertility
    • assisted reproductive technologies, including, but not limited to, in-vitro fertilization, artificial insemination, gamete and zygote intrafallopian tube transfer and intracytoplasmic sperm injection
    • surgery and/or non-surgical treatment for gender change
    • reversal of sterilization
    • travel expenses, except as specified
    • psychological testing for educational purposes for children or adults
    • common first-aid supplies such as adhesive tape, gauze, antiseptics, ace bandages, and surgical appliances that are stock items, such as braces, elastic supports, semi-rigid cervical collars or surgical shoes
    • expenses for acupressure, prayer, religious healing including services, and naturopathic, naprapathic, or homeopathic services or supplies
    • expenses for memberships in or visits to health clubs, exercise programs, gymnasiums or other physical fitness facilities
    • operating room fees for surgery, surgical trays and sterile packs done in a non-state-licensed facility including the doctor's office
    • orthotics for routine foot care (including dispensing of surgical shoe(s)
      and pre- and post-operative X-rays)
    • routine hearing exams
    • Ambulette, except as provided in footnote 6 on page 78
    • Private-duty nursing
    • the following specific preventive care services:
      - screening tests done at your place of work at no cost to you
      - free screening services offered by a government health department
      - tests done by a mobile screening unit, unless a doctor not affiliated with the mobile unit prescribes the tests
    • the following specific emergency services:
      - use of the emergency room to treat routine ailments because you have no regular doctor or because it is late at night (and the need for treatment does not meet the Plan's definition of emergency - see page 74)
      - use of the emergency room for follow-up visits
    • the following specific maternity care services:
      - days in hospital that are not Medically Necessary (beyond the 48-hour/96-hour stays the Fund is required by law to cover)
      - private room (If you use a private room, you pay the difference between the cost for the private room and a semi-private room. The additional cost does not count toward your deductible or co-insurance.)
      - out-of-network birthing center facilities
      - private-duty nursing
    • the following specific inpatient hospital care expenses:
      - private-duty nursing
      - private room (If you use a private room, you pay the difference between the cost for the private room and a semi-private room. The additional cost does not count toward your deductible or co-insurance.)
      - diagnostic inpatient stays, unless connected with specific symptoms that if not treated on an inpatient basis could result in serious bodily harm or risk to life
      - any part of a hospital stay that is primarily custodial
      - elective cosmetic surgery19 or any related hospital expenses or treatment of any related complications
      - hospital services received in clinic settings that do not meet Empire's definition of a hospital or other covered facility
      - effective 1/1/09, bariatric surgery at a facility that is not accredited by the American College of Surgeons
    • the following specific outpatient hospital care expenses:
      - certain same-day surgeries not pre-certified as Medically Necessary by the Health Services Program
      - routine medical care including, but not limited to, inoculation, vaccination, drug administration or injection, excluding chemotherapy
      - collection or storage of your own blood, blood products or semen
    • the following out-of-network services and/or expenses
      - kidney dialysis for treatment started after 4/5/07
      - bariatric surgery effective 1/1/09
      - skilled nursing facility
      - hospice care facility
      - home infusion therapy
      - birthing centers
      - outpatient physical therapy
      - durable medical equipment
      - prosthetics/orthotics
      - outpatient occupational, speech, and vision therapies
    • the following specific equipment:
      - air conditioners or purifiers
      - humidifiers or de-humidifiers
      - exercise equipment
      - swimming pools
    • skilled nursing facility care that primarily:
      - gives assistance with daily living activities
      - is for rest or for the aged
      - is convalescent care
      - is sanitarium-type care, or
      - is a rest cure
    • the following specific home health care services:
      - custodial services, including bathing, feeding, changing or other services that do not require skilled care
      - out-of-network home infusion therapy
    • the following specific physical, occupational, speech or vision therapy services:
      - therapy to maintain or prevent deterioration of the patient's current physical abilities
      - treatment for developmental delay, including speech therapy
    • the following specific vision care services:
      - expenses for surgical correction of refractive error or refractive keratoplasty procedures including, but not limited to, radial keratotomy (RK), photo-refractive keratotomy (PRK) and laser in situ keratomileusis 21 (LASIK) and its variants
      - eyeglasses, contact lenses and the examination for their fitting except following cataract surgery
      - routine vision care
    • the following services that may be covered elsewhere under the 1201 Health and Welfare Fund:
      - dental treatment, except surgical removal of impacted teeth or treatment of sound natural teeth injured by accident if treated within 12 months of the injury
      - all prescription drugs and over-the-counter drugs, self-administered injectables, vitamins, vitamin therapy, appetite suppressants, or any other type of medication, unless specifically indicated
      - behavioral health and substance abuse care services, including inpatient and outpatient behavioral care, as well as inpatient and outpatient substance abuse treatment (detoxification and 32 May 1, 2010 rehabilitation). However, see"Behavioral Health and Substance Abuse Benefit," pages 33-40, to find out how these expenses are covered.
      - services of a nutritionist and nutritional therapy or counseling, except as provided on pages 22, 27 and 81
      - a skilled nursing facility that primarily treats drug addiction or alcoholism (see"Behavioral Health and Substance Abuse Benefit," pages 33-40, to find out how drug addiction or alcoholism may be covered)
      - false teeth
    • the following miscellaneous health care services and expenses:
      - services performed in nursing or convalescent homes; institutions primarily for rest or for the aged; rehabilitation facilities (except for physical therapy); spas; sanitariums; or infirmaries at schools, colleges or camps
      - injury or sickness that arises out of any occupation or employment for wage or profit for which there is Workers' Compensation or occupational disease law coverage (for information about subrogation of benefits, see pages 55-57)
      - injury or sickness that arises out of any act of war (declared or undeclared) or military service of any country
      - injury or sickness that arises out of a criminal act (other than domestic violence) by the covered person, or an intentionally selfinflicted injury that is not the result of mental illness
      - expenses for services or supplies for which a covered person receives payment or reimbursement from casualty insurance or as a result of legal action, or expenses for which the covered person has already been reimbursed by another party who was responsible because of negligence or other tort or wrongful act of that party (for information about subrogation of benefits, see pages 55-57)
      - expenses reimbursable under the"no-fault" provisions of a state law
      - services covered under government programs, except under Medicare, Medicaid or where otherwise noted
      - any hospital care received outside of the U.S. that is not emergency care
      - government hospital services, except specific services covered under a special agreement between Empire and a governmental hospital or services in United States Veterans' Administration or Department of Defense hospitals for conditions not related to military service
      - treatment or care for temporomandibular disorder or temporomandibular joint disorder (TMJ) syndrome
      - services such as laboratory, X-ray and imaging, and pharmacy services from a facility in which the referring doctor or his or her immediate family member has a financial interest or relationship
      - services given by an unlicensed provider or performed outside the scope of the provider's license
      - charges for services a relative provides
      - charges that exceed the maximum allowed amount or lifetime maximum for that service or supply
      - services performed at home, except for those services specifically noted in this booklet as covered either at home or in an emergency
      - services usually given without charge, even if charges are billed
      - services performed by hospital or institutional staff that are billed separately from other hospital or institutional services, except as otherwise specified in this booklet.

    See footnotes 19 and 20 on page 81.

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    Behavioral Health and Substance Abuse Benefit

    Your Plan provides you and your eligible dependents with a behavioral health and substance abuse benefit which is administered by Managed Health Network (MHN). This benefit provides services for mental health or behavioral issues as well as assistance with substance abuse treatments. Services are available both in the hospital and on an outpatient basis. All behavioral health care and substance abuse services must be provided by an MHN participating hospital or provider. There is no coverage for services received from a non-participating MHN provider except in cases of an emergency.

    MHN is an independent organization that manages a network of behavioral health specialists and also arranges consultations, assessments and referrals. This network is separate from and not part of the Empire BlueCard network.

    These benefits for behavioral and substance abuse treatment are payable for in-network care only. You must use a participating MHN network provider to get benefits. If you use an out-of network facility or provider, no benefits are payable.

    All services, including counseling, behavioral and substance abuse treatment, both inpatient and outpatient, require referral from MHN. If you need services or want to discuss a problem, call MHN at 1-800-798-2150.

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    Behavioral and Substance Abuse Services

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    Inpatient. As long as you go to an in-network facility and the stay has been pre-certified (see below), the Plan pays the allowed amount for up to 30 days per year, including partial hospitalization and day programs. If you use an out-of-network facility and/or do not pre-certify care, no benefits are payable unless it is an emergency. If there is an emergency, the patient should first go to the nearest emergency room, then call MHN (a provider or relative may make the call for the patient). As long as MHN is contacted within 48 hours of admission, the Plan will pay benefits for charges that are determined to be emergency care charges. If the facility is not an MHN network provider, the patient may be transferred to a network facility once the emergency has passed.

    Benefits for inpatient substance abuse rehabilitation are payable only once in each person's lifetime. This limit does not apply when the only care provided is for detoxification.

    Outpatient. You are covered for up to 40 visits per year when you see an MHN participating provider on an outpatient basis. For outpatient treatment from a network provider your first eight (8) visits have a $0 co-payment. Then for visits 9-40 you must pay a $15 co-payment per visit. If you use an out-of-network therapist or do not pre-certify care, no benefits are payable. Outpatient treatment may include individual and group psychotherapy, couples and family treatment, psychiatric and medication evaluations, and ongoing medication management, depending on the patient's needs. Outpatient services are subject to a limit of 40 visits per year.

    Psychological testing is covered as long as it is clinically indicated and pre-certified. Psychological testing for educational purposes is not covered.

    Electro-convulsive therapy (ECT) is covered on either an inpatient and outpatient basis, subject to the applicable limits and/or co-payments described above, as long as it is pre-certified and received from a network provider.

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    Confidentiality

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    MHN is committed to protecting your privacy, and all contact with them is strictly confidential as required by Federal and state laws. If anyone else requests information, MHN must first get your approval before they can release it. All services are kept confidential in accordance with Federal, state and local laws, and professional standards of confidentiality. Among the situations where the provider is required by law to notify authorities are instances of child abuse, elder abuse or a professional determination that the patient is a threat to personal safety.

    Pre-Certifying Behavioral or Substance Abuse Services

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    To pre-certify care, call MHN toll-free at 1-800-798-2150. If you are unable to make the call yourself, your MHN network provider, treatment facility or a family member can call instead. As part of the pre-certification process, your MHN case manager will determine eligibility and help make arrangements for required admissions, transportation to and from facilities where necessary, and ongoing case management during and after hospitalization.

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    Eligible Providers

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    For behavioral health care purposes, "providers" include psychiatrists, psychologists and licensed social workers with six or more years of postdegree experience, who are certified by an accrediting organization to provide psychiatric or psychological services within the scope of their practice, including the diagnosis and treatment of mental and behavioral disorders.

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    Conditions for Coverage

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    In order to be covered, any expenses you incur for behavioral and substance abuse services must be in-network, medically necessary and:

    • the requested services must provide for the diagnosis and/or active treatment of a current substance abuse-related disorder or a condition listed as an Axis I disorder in the most recent edition of the "Diagnostic and Statistical Manual of Mental Disorders" by the American Psychiatric Association
    • the proposed treatment plan must represent an active, necessary and appropriate intervention for the timely resolution of the patient's symptoms and the restoration to baseline level of functioning (proposed services cannot be custodial in nature)
    • the type, level and length of the proposed services and setting must be consistent with MHN's level-of-care criteria and guidelines, and must be rendered in the least restrictive level of care in which the patient can be safely and effectively treated
    • the proposed treatment must not be experimental in nature (that is, safety and efficacy must have been clearly demonstrated and widely accepted in the modern psychiatric literature)
    • the proposed treatment plan must be shown in peer-reviewed journals to be at least equally effective in bringing about a rapid resolution of symptoms when compared to possible alternative treatment interventions, and
    • the proposed treatment plan must utilize clinical services in an efficient manner when compared to alternative treatment interventions and must contribute to effective management of the patient's benefits.

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    What Is Not Covered

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    Your Behavioral Health benefit does not include coverage for any of the services, supplies or charges listed below. However, some of these items are covered under medical/hospital; check the medical/hospital section of this booklet (see pages 15-33).

    • services received or expenses incurred before the patient's coverage began or after the patient's coverage ended, except as specifically stated herein
    • outpatient treatment for any medically treated illness
    • treatment or services for mental retardation or autism
    • services by counselors who are not in the MHN Behavioral Health network
    • testing, treatment or counseling required by law or court
    • formal psychological evaluations and fitness-for-duty opinions
    • legal advice
    • long term hospitalization for residential or chronic care
    • treatment of detoxification in newborns
    • treatment of congenital and/or organic disorders (this includes, without limitation, Alzheimer's disease, mental retardation (other than the initial diagnosis), organic brain disease, delirium, dementia, amnesic disorders and other cognitive disorders as defined in the "Diagnostic and Statistical Manual of Mental Disorders")
    • treatment for chronic pain and other pain disorders, smoking cessation, nicotine dependence, nicotine withdrawal and nicotine-related disorders
    • treatment of obesity and eating disorders-other than the diagnosis and treatment of anorexia and bulimia nervosa as defined in the "Diagnostic and Statistical Manual of Mental Disorders"-unless otherwise required by law
    • private hospital rooms and/or private-duty nursing, unless medically necessary and authorized by MHN
    • ancillary services such as:
      - vocational rehabilitation
      - behavioral training
      - speech or occupational therapy
      - sleep therapy
      - employment counseling
      - training or educational therapy for reading or learning disabilities
      - other education services
    • testing, screening or treatment for:
      - learning disorders, expressive language disorders, mathematics disorder, phonological disorder and communication disorder
      - motor skills disorders and development coordination disorder
      - all disorders of infancy and early childhood, and development disorders including, but not limited to, communication disorders, pervasive developmental disorders, autistic disorder, Rett's disorder, Asperger's disorder (except as otherwise required by law)
      - disorders resulting from general medical conditions, including, but not limited to, catatonic disorder due to general medical condition, personality change due to general medical disorder, narcolepsy, stuttering, stereotypic movement disorders, sleep disorders, tic disorders, elimination disorder and sexual dysfunctions 38 May 1, 2010
      - personality disorders
      - pedophilia
      - primary sleep disorders, including primary hypersomnia, dyssomnia and insomnia
      - age-related cognitive decline
    • treatment of conditions that are medical in nature, even when such conditions may have been caused by a mental disorder
    • treatment by providers other than those within licensing categories that are recognized by MHN as providing medically necessary services in accordance with applicable medical community standards
    • treatment rendered for conditions not listed as an Axis I disorder (V Code diagnoses listed as Axis I disorders are also excluded unless otherwise specified in the Plan)
    • services beyond what is authorized by MHN's pre-certification and concurrent review procedures
    • psychological testing (except as conducted by a licensed psychologist for assistance in treatment planning, including medication management or diagnostic clarification) and specifically excluding all educational, academic and achievement tests, psychological testing related to medical conditions or to determine surgical readiness, and automated computer-based reports
    • all prescription or non-prescription drugs and laboratory fees, except for drugs and laboratory fees prescribed by a provider in connection with inpatient treatment (if prescribed in the course of outpatient treatment)
    • inpatient services, treatment, or supplies rendered in a non-emergency situation by a non-participating provider, unless authorized by MHN
    • inpatient stays in excess of 30 days per year for behavioral and substance abuse treatment combined
    • inpatient stays in excess of 30 days lifetime for substance abuse treatment
    • outpatient care in excess of 40 visits per year for behavioral and substance abuse combined
    • emergency behavioral or substance abuse hospital admissions that have not been pre-certified within 48 hours of admission
    • emergency room services not provided by a psychiatrist directly related to the treatment of a mental disorder in accordance with the limitations listed above
    • damage to a hospital or facility caused by the patient
    • health care services, treatment or supplies determined to be experimental by MHN in accordance with accepted behavioral standards, except as otherwise required by law
    • health care services, treatment or supplies:
      - provided as a result of Workers' Compensation law or similar legislation (see page 54)
      - obtained through, or required by, any governmental agency or program
      - caused by the conduct or omission of another party for which the patient has a claim for damages or relief or has been reimbursed (for information about subrogation of benefits, see pages 55-57)
    • health care services, treatment or supplies for military service disabilities for which treatment is reasonably available under governmental health care programs
    • treatment for biofeedback, acupuncture or hypnotherapy
    • health care services, treatment or supplies rendered to the patient that are not medically necessary (this includes, but is not limited to, services, treatment or supplies primarily for rest or convalescence, custodial or domiciliary care as determined by MHN)
    • services for which:
      - the person is not legally obligated to pay
      - no charge is made to the person
      - no charge would have been made to the person in the absence of insurance
    • services in connection with conditions caused by an act of war
    • conditions caused by release of nuclear energy, whether or not the result of war
    • professional services received from a person who lives in the patient's home or who is related to the patient by blood or marriage
    • any services or supplies to the extent they are covered and primary under Parts A or B of Medicare if the patient is either enrolled in Part A of Medicare (whether or not the patient is enrolled in Part B of Medicare), or is entitled to enroll in Medicare and has made the required number of quarterly contributions to the Social Security System (whether or not the patient has actually enrolled in Medicare or claimed Medicare benefits)
    • all other services, confinements, treatments or supplies not provided primarily for the treatment of the specific conditions described in the Behavioral Health and Substance Abuse benefit section of this booklet, and/or
    • all other services, confinements, treatments or supplies specifically included as covered services elsewhere in this Plan.

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    Life Insurance Benefits

    Benefit Amount

    Your life insurance coverage, which is administered by MetLife, is $25,000. Life insurance benefits are payable to your beneficiary if you die while coverage is in effect.

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    Naming a Beneficiary

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    Your beneficiary will be the person or persons you name in writing on a form that is kept on file at MetLife. Your beneficiary can be anyone you choose, and you can change your beneficiary designation at any time by completing and submitting a new form to MetLife. You can also go to www.seiu32bj.org, select the 32BJ Funds icon and click on MetLife under Important Links.

    If you do not name a beneficiary, or if your beneficiary dies before you and you have not named a new beneficiary, your life insurance benefit will be payable in the following order:

    1. your wife or husband, if living
    2. your living children, equally
    3. your living parents, equally, and
    4. if none of the above, to your estate.

    The Plan does not pay life insurance benefits to a designated beneficiary who is involved in any way in the purposeful death of the participant. In a case where this rule applies, if there is no named beneficiary who can receive the benefits, they will be paid in the order listed immediately above.

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    Life Insurance Disability Extension

    If you are disabled and receiving short-term disability or Workers' Compensation benefits, your life insurance will continue for six months from the date of disability, or until your disability ends, whichever happens first.

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    When Coverage Ends

    Life insurance coverage ends 30 days after your covered employment ends, except as provided above or if you have Fund-paid COBRA due to disability or arbitration (see page 7 and pages 60-63). See page 65 for information about converting your group life insurance to an individual life insurance policy.

    Accidental Death & Dismemberment (AD&D) Benefits

    Accidental Death & Dismemberment (AD&D) insurance, which is administered by MetLife, applies to accidents on or off the job, at home or away from home. This is unlike Workers' Compensation insurance, which covers you only on the job. You are eligible while in covered employment and for 30 days after your covered employment ends.

    Your AD&D benefit is in addition to your life insurance and is payable if you die or become dismembered as a result of an accident within 90 days after that accident.

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    How AD&D Benefits Work

    Your AD&D insurance coverage is shown in the following chart. Benefits are payable to your beneficiary if you die, or to you if you have an accident and suffer one of the specific injuries listed in the chart on the following page. Benefits will not be paid if your death or injury was caused by anything excluded under"What Is Not Covered" on the following page. Your beneficiary will be the same as your life insurance beneficiary on file with MetLife, unless you choose otherwise. See page 40 for more information about naming a beneficiary.

    Loss Benefit Payable

    Life

    $25,000

    Both hands at or above the wrist; or both feet at or above the ankle; or sight in both eyes; or any combination of hand, foot and sight in one eye

    $25,000

    One hand at or above the wrist; or one foot at or above the ankle; or sight in one eye

    $12,500

    "Loss" of a hand or foot means the actual and complete severance through or above the wrist or ankle joint. Loss of sight means the irrevocable and complete loss of sight.

    For all covered losses caused by all injuries that you sustain in one accident, not more than the full amount will be paid.

    Contact MetLife to claim AD&D benefits.

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    What Is Not Covered

    AD&D insurance benefits will not be paid for injuries that result from any of the following causes:

    • physical or mental illness, or diagnosis of or treatment for the illness
    • an infection, unless it is caused by an external wound that can be seen and that was sustained in an accident
    • suicide or attempted suicide
    • injuring oneself on purpose
    • the use of any drug or medicine
    • a war, or a warlike action in time of peace
    • committing or trying to commit a felony or other serious crime or an assault
    • the injured party was intoxicated at the time of the accident and was operating a vehicle or other device involved in the incident. "Intoxicated" means that the injured person's blood alcohol level met or exceeded the level that creates a legal presumption of intoxication under the laws of the jurisdiction in which the accident occurred.

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    When Coverage Ends

    AD&D insurance coverage ends 30 days after you terminate employment. Like your life insurance, your AD&D coverage can continue while you have Fund-paid COBRA due to disability or arbitration (see page 7, and pages 60-63).

    Claims and Appeals Procedures

    Benefit Amount

    This section describes the procedures for filing claims for Plan benefits. It also describes the procedure for you to follow if your claim is denied, in whole or in part, and you wish to appeal that decision.

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    Claims for Benefits

    A claim for benefits is a request for Plan benefits that is made in accordance with the Plan's claims procedures. Please note that the following are not considered claims for benefits:

    • inquiries about the Plan's provisions or eligibility that are unrelated to any specific benefit claim, and
    • a request for prior approval of a benefit that does not require prior approval by the Plan.

    Filing Hospital and Medical Claims

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    Remember if you use network providers, you do not have to file claims. The providers will do it for you. If you use out-of-network providers, here are some steps to take to make sure your hospital or medical claim gets processed accurately and on time.

    • File claims as soon as possible (and never later than 18 months after the date of service).
    • Complete all information requested on the form.
    • Submit all claims in English or with an English translation. Claims not in English will not be processed and will be returned to you.
    • Attach original bills or receipts. Photocopies will not be accepted.
    • If you have other coverage and Empire is the secondary payer, submit the original or a copy of the primary payer's Explanation of Benefits (EOB) with your itemized bill (see"Coordination of Benefits" on pages 52-55).
    • Keep a copy of your claim form and all attachments for your records.

    Filing Behavioral Health and Substance Abuse Claims

    If you use network providers, you do not have to file claims. The providers will do it for you. If you do not use network providers, then no benefit is available.

    If you have other coverage and MHN is the secondary payer, submit the original or a copy of the primary payer's Explanation of Benefits (EOB) with your itemized bill (see"Coordination of Benefits" on pages 52-55).

    Filing Life Insurance and AD&D Claims

    To file a claim for a life insurance benefit, your beneficiary must complete a claim form and submit a certified copy of your Death Certificate. A claim for life insurance should be filed as soon as possible after the participant's death.

    To file for an AD&D benefit, you must complete a claim form. In the event of your death, your beneficiary must submit a certified copy of the Death Certificate along with a completed claim form. A claim for an AD&D benefit must be filed within 90 days after the loss is incurred.

    For both life insurance and AD&D claims, you can get claim forms by contacting MetLife.

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    Where to Send Claim Forms

    Benefit Filing Address

    Medical/Hospital (out-of-network only; no claim forms are necessary for in-network care)

    Empire BlueCross BlueShield P.O. Box 1407
    Church Street Station
    New York, NY 10008-1407

    Attn: Institutional Claims Department (for hospital claims); or, Attn: Medical Claims Department (for medical/ambulance claims)

    Behavioral Health and Substance Abuse (no claim forms are necessary)

    Not Applicable

    Life Insurance

    Accidental Death & Dismemberment

    Metropolitan Life Insurance Company
    Group Life Claims
    P.O. Box 6100
    Scranton, PA 18505-6100

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    Approval and Denial of Claims

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    There are separate claims denial and approval processes for Health Services Claims (hospital/medical, behavioral health and substance abuse). These processes are described separately below. Please review this information to ensure that you are fully aware of these processes and what you need to do in order to comply.

    Health Service Claims (hospital/medical, behavioral health and substance abuse)

    The time frames for deciding whether health service claims are accepted or denied depend on whether your claim is a pre-service, an urgent care, a concurrent care or a post-service claim.

    • Pre-service claims. This is a claim for a benefit for which the Plan requires approval of the benefit (in whole or in part) before medical care is obtained. Prior approval of services is required for inpatient hospital benefits (see pages 21-23), certain outpatient hospital benefits (see pages 21-23), and behavioral health and substance abuse benefits (see page 33-40). For properly filed pre-service claims, you and/or your doctor will be notified of a decision within 15 days from receipt of the claim unless additional time is needed. The time for response may be extended up to 15 days if necessary due to matters beyond the control of the claims reviewer. You will be notified of the circumstances requiring the extension of time and the date by which a decision is expected to be rendered.

      If you improperly file a pre-service claim, you will be notified as soon as possible, but not later than 5 days after receipt of the claim, of the proper procedures to be followed in refiling the claim. You will only receive notice of an improperly filed pre-service claim if the claim includes:

      - your name
      - your current address
      - your specific medical condition or symptom, and
      - a specific treatment, service or product for which approval is requested.
      Unless the claim is refiled properly, it will not constitute a claim. If an extension is needed because additional information is needed from you, the extension notice will specify the information needed. In that case, you and/or your doctor will have 45 days from receipt of the notification to supply the additional information. If the information is not provided within that time, your claim will be denied. During the period in which you are allowed to supply additional information, the normal period for making a decision on the claim will be suspended. The deadline is suspended from the date of the extension notice either for 45 days or until the date the claims reviewer receives your response to the request (whichever is earlier). The claims reviewer will then have 15 days to make a decision on a pre-service claim and notify you of the determination.
    • Urgent care claims. This is a claim for medical care or treatment that, if the time periods for making pre-service claim determinations were applied, could jeopardize your life, health or ability to regain maximum function, or in the opinion of a doctor, result in your having unmanageable, severe pain.

      Whether your treatment is considered urgent care is determined by an individual acting on behalf of the Fund applying the judgment of a prudent person who possesses an average knowledge of health and medicine. Any claim that a doctor with knowledge of your medical condition determines is an urgent care claim shall automatically be treated as such. If you (or your authorized representative*) file an urgent care claim, you will be notified of the benefit determination as soon as possible, taking into account medical emergencies, but no later than 72 hours after receipt of your claim.

      However, if you do not give enough information for the claims reviewer to determine whether, or to what extent, benefits are payable, you will receive a request for more information within 24 hours. You will then have up to 48 hours, taking into account the circumstances, to provide the specified information to the claims reviewer. You will then be notified of the benefit determination within 48 hours after:

      - the claims reviewer's receipt of the specified information or, if earlier,
      - the end of the period you were given to provide the requested information.

      If you do not follow the Plan's procedures for filing an urgent care claim, you will be notified within 24 hours of the failure and the proper procedures to follow. This notification may be oral, unless you request written notification. You will only receive notification of a procedural failure if your claim includes:

      - your name
      - your specific medical condition or symptom, and
      - a specific service, treatment or product for which approval is requested.
    • Concurrent claims. This is a claim that is reconsidered after an initial approval was made and results in a reduction, termination or extension of a benefit. An example of this type of claim would be an inpatient hospital stay originally certified for five days that is reviewed at three days to determine if additional days are appropriate. Here the decision to reduce, end or extend treatment is made while the treatment is taking place.

      Any request by a claimant to extend approved treatment will be acted upon by the claims reviewer within 24 hours of receipt of the claim, provided the claim is received at least 24 hours before the approved treatment expires.
    • Post-service claims. This is a claim submitted for payment after health services and treatment have been obtained.

      Health Fund - Suburban Plan for the School District of Philadelphia 47 Ordinarily, you will receive a decision on your post-service claim within 30 days from receipt of the claim. This period may be extended one time for up to 15 days if the extension is necessary due to extraordinary matters. If an extension is necessary, you will be notified, before the end of the initial 30-day period, of the circumstances requiring the extension of time and the date by which a determination will be made.

      If an extension is needed because additional information is needed from you, the extension notice will specify the information needed. In that case you will have 45 days from receipt of the notification to supply the additional information. If the information is not provided within that time, your claim will be denied. During the period in which you are allowed to supply additional information, the normal period for making a decision on the claim will be suspended. The deadline is suspended from the date of the extension notice either for 45 days or until the date the claims reviewer receives your response to the request (whichever is earlier). Within 15 days after the expiration of this time period, you will be notified of the decision.

    * A health care professional with knowledge of your medical condition or someone to whom you have given authorization may act as an authorized representative in connection with urgent care.

    Life Insurance and AD&D Claims

    If you or your beneficiary file a claim for either life insurance or AD&D benefits, MetLife will make a decision on the claim and notify you of the decision within 90 days. If MetLife requires an extension of time due to matters beyond its control, they are permitted an additional 90 days. MetLife will notify you, your authorized representative, your beneficiary or the executor of your estate, as applicable, before the expiration of the original 90-day period of the reason for the delay and when the decision will be made. A decision will be made within the 90-day extension period and you will be notified in writing by MetLife.

    Notice of Decision

    You will be provided with written notice of a denial of a claim (whether denied in whole or in part) or if any adverse benefit determination is made (for example, the Plan pays less than one hundred percent of the claim). For urgent care and pre-service claims, you will receive notice of the determination even when the claim is approved. The timing for delivery of this notice depends on the type of claim as described on page 49-51.

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    Appealing Denied Claims

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    An appeal is a request by you or your authorized representative to have an adverse benefit determination reviewed and reconsidered.

    Filing an Appeal

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    You have 180 days from the date of the original claim denial letter to file an appeal following the notification of a denied claim.

    Your appeal must include your identification number, dates of service in question and any relevant information in support of your appeal.

    If you submit a written request, you will be provided access to or copies of all documents, records or other information relevant to your appeal (including, in the case of an appeal involving a disability determination, the identity of any medical or vocational experts whose advice the claims reviewer used in connection with the decision to deny your application).

    A document, record or other information is relevant for review if it falls into any of the following categories:

    • The claims reviewer relied on it in making a decision.
    • It was submitted, considered or generated in the course of making a decision (regardless of whether it was relied on).
    • It demonstrates compliance with the claims reviewer's administrative processes for ensuring consistent decision-making.
    • It constitutes a statement of Plan policy regarding the denied treatment or service.

    You (or your authorized representative) may submit issues, comments, documents and other information relating to the appeal (regardless of whether they were submitted with your original claim).

    If you do not request a review of a denied claim within 180 days, you will waive your right to a review of the denial. However, the applicable reviewer may not enforce this waiver if you can prove that you have a good reason for missing this deadline, provided you ask the applicable reviewer in writing to review the denial and you do so within one year after the date of the original claim denial letter. You must file an appeal with the appropriate party and follow the process completely before you can bring an action in court. Failure to do so may prevent you from having any legal remedy.

    Where to File an Appeal

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    Benefit Write to: Or Call

    Medical and Hospital

    Empire BlueCross BlueShield
    Medical Management Appeals
    Mail Drop R/6 O, P.O. Box 11825
    Albany, NY 12211-0825

    1-866-316-3394

    Behavioral Health and Substance Abuse

    MHN
    Appeals and Grievance Department
    1600 Los Gamos Drive, Suite 300
    San Rafael, CA 94903-1807

    1-800-798-2150

    Life Insurance

    Accidental Death & Dismemberment

    Metropolitan Life Insurance Company
    Group Life Claims
    P.O. Box 6100, Scranton, PA 18505-6100 Fax: 1-570-558-8645

    Appeals are only accepted in writing

    Time Frames for Decisions on Appeals

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    The time frame within which a decision on an appeal will be made depends on the type of claim for which you are filing an appeal.

    Expedited Appeals for Urgent Care Claims

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    If your claim involves urgent care for medical, hospital, behavioral health and substance abuse benefits, you can file an expedited appeal if your provider believes an immediate appeal is warranted because delay in treatment would pose an imminent or serious threat to your health or ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. This appeal can be filed in writing or orally. You can discuss the reviewer's determination and exchange any necessary information over the phone, via fax or any other quick way of sharing. You will receive a response within 72 hours of your request.

    Pre-Service or Concurrent Medical, Hospital, Behavioral Health and Substance Abuse Claim Appeal

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    If you file an appeal of a pre-service (service not yet received) or concurrent (service currently being received) claim that does not involve urgent care, a decision will be made and you will be notified within 30 days of the receipt of your appeal. An appeal of a cessation or reduction of a previously approved benefit will be decided as soon as possible, but in any event prior to the cessation or reduction of the benefit.

    Post-Service Medical, Hospital, Behavioral Health and Substance Abuse Claim Appeal

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    will be notified within 60 days of the receipt of your appeal.

    Voluntary Second Level Appeal of a Medical, Hospital, Life Insurance, AD&D or Behavioral Health and Substance Abuse Claim

    ALERT: 5/22/13 NEW Click here for important benefit changes>>

    Once you have been notified regarding the outcome of your timely* appeal of a medical, hospital, life insurance, AD&D or behavioral health and substance abuse claim, you have exhausted all required internal appeal options. If you disagree with the decision, you are free to file a civil action under 502(a) of ERISA. No lawsuit may be started more than three years after the date of the appeal denial letter. Alternately, you may file a voluntary appeal with the Appeals Committee of the Board of Trustees. This voluntary appeal must be filed within 180 days of the appeal denial letter provided to you by the applicable reviewer as listed on the chart on page 49.

    The voluntary level of appeal is available only after you (or your representative) have pursued the appropriate mandatory appeals process required by the Plan, as indicated previously. This second level of appeal is completely voluntary; it is not required by the Plan and is only available if you (or your representative) request it. The Plan will not assert a failure to exhaust administrative remedies where you or your authorized representative elect to pursue a claim in court rather than through the voluntary level of appeal. The Plan will not impose fees or costs on you (or your representative) because you or your authorized representative choose to invoke the voluntary appeals process. Your decision as to whether or not to submit a benefit dispute to the voluntary level of appeal will have no effect on your rights to any other benefits under the Plan. Upon your request, the Plan will provide you (or your representative) with sufficient information to make an informed judgment about whether to submit a claim through the voluntary appeal process, including your right to representation.

    Your voluntary appeal must include your identification number, dates of service in question, and any additional information that supports your appeal. You (or your authorized representative) can write to the Appeals Committee at the following address:

    Building Service 32BJ Health Fund Board of Trustees - Appeals Committee 101 Avenue of the Americas New York, NY 10013-1991

    * See pages 47-51. The Appeals Committee does not hear voluntary appeals for claims for which the initial mandatory appeals were not timely filed with the appropriate appeals reviewer. If your appeal was denied as untimely by the appeals reviewer, there is no voluntary appeal to the Board of Trustees' Appeals Committee.

    Appeal Decision Notice

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    You will be notified in writing of the decision of your appeal. The timing for delivery of this notice depends on the type of claim that was appealed.

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    Further Action

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    All decisions on appeal will be final and binding on all parties, subject only to your right to bring a civil action under Section 502(a) of ERISA after you have exhausted the Plan's appeal procedures.

    You may not start a lawsuit to obtain benefits until you have completed the mandatory appeals process and a final decision has been reached, or until the appropriate time frame described in this booklet has elapsed since you filed an appeal and you have not received a final decision or notice that an extension will be necessary to reach a final decision. In addition, no lawsuit may be started more than three years after the date on which the applicable appeal was denied. If there is no decision on the appeal, no lawsuit may be started more than three years after the time when the Appeals Committee should have decided the appeal.

    If you have any questions about the appeals process, please contact the Compliance Office.

    Incompetence

    If someone who is entitled to benefits from the Plan is determined to be unable to care for his or her affairs because of illness, accident or incapacity, either mental or physical, any payment due may be made instead to someone else such as a spouse or a legal custodian. The Fund will decide who is entitled to benefits in cases like this.

    Mailing Address

    It is important that you notify Member Services whenever your address changes. If you become unreachable, the Fund will hold any benefit payments due you, without interest, until payment can be made. You are considered unreachable if a letter sent to you by first-class mail to your last known address is returned.

    Coordination Of Benefits

    You or your dependents may have health care coverage under two plans. For example, your spouse may have employer-provided health insurance or be enrolled in Medicare. When this happens, the two plans will coordinate their benefit payments so that the combined payments do not exceed the allowable charges (or actual cost, if less). This process, known as Coordination of Benefits (COB), establishes which plan pays first and which one pays second. The plan that pays first is the primary plan; the plan that pays second is the secondary plan. The primary plan may reimburse you first and the secondary plan may reimburse you for the remaining expenses to the maximum of the allowable charges for the covered services.

    Your Plan uses the Non-Duplication of Benefits application of COB. This means that when this Plan is the secondary plan, it determines how much it would have paid as the primary plan and then subtracts whatever the primary plan paid as its benefit. Then your Plan, the secondary plan, pays the difference. If there is no difference, then your plan, as the secondary, pays nothing.

    Coordination of Benefits will ensure that you receive the maximum benefit allowed by the Plan, while possibly reducing the cost of services to the Plan. You will not lose benefits you are entitled to under this plan and may gain benefits if your spouse's plan has better coverage in any area.

    Except for the situations like Medicare and TRI-CARE described on pages 53-54, the rules for determining which plan is primary are as follows:

    • If the other plan does not have a Coordination of Benefits provision with regard to the particular expense, that plan is always primary.
    • The plan that covers the patient as an active employee is primary and the plan that covers the patient as a dependent is secondary.
    • If the patient is covered both as an active employee (or as a dependent of an active employee) and as either a laid-off employee or a retired employee, then the active employee's plan will be primary. However, if the other plan does not have this rule and the two plans do not agree as to which coverage is primary, then this rule will not apply.
    • If the patient is a dependent child of parents who are not separated or divorced, then the plan covering the parent whose birthday falls earlier in the calendar year is primary and pays first. If the other plan does not use this"birthday rule", then that plan is primary unless the primary plan is already determined under the above rules.
    • If the patient is a dependent child of parents who are legally separated or divorced, the plan of the parent with custody will be primary; the other parent's plan will be secondary. In the event the parent with custody has remarried, the plan of the parent (or stepparent) with custody will be primary and the plan of the parent without custody will be secondary. If there is a court decree giving one parent financial responsibility for the medical expenses, then that parent's plan becomes primary without regard to the other rules in this paragraph.
    • If none of the above rules establishes which plan is the primary plan, the plan that has covered the patient the longest, continuously, in the period of coverage in which the expense is incurred is the primary plan.

    If both you and your spouse are participants under this Plan, your benefits are coordinated in the same manner as anyone else (that is, as if you and your spouse were covered under different plans). You will not receive reimbursement for more than the allowable charges for the covered services, and you will not be reimbursed for required co-payments.



    Medicare.

    • If you (or a dependent) become eligible for Medicare due to age or disability (according to the standards applied by Social Security) and you are in covered employment, you or your dependent(s) can keep or cancel (spouse can cancel when he or she reaches age 65) your coverage under this Plan. If you (or your dependent) decide to be covered by both this Plan and Medicare, this Plan will be primary and Medicare will be secondary as long as you remain in covered employment.
    • If you are not in covered employment and you (or a dependent) are eligible for Medicare due to age or disability (according to the standards applied by Social Security), Medicare is primary and this Plan is secondary for each covered family member who is eligible for Medicare. Those covered family members who are not eligible for Medicare continue to receive primary coverage from this Plan.

    End-stage Renal Disease. For covered patients with end-stage renal disease, Medicare is the secondary payer of benefits during the first 30 months of treatment. After this 30-month period is over, Medicare permanently becomes the primary payer. Note that this Plan will pay as the secondary plan after the 30-month period even if you (or your dependent) fail to enroll in Medicare Part B.

    TRI-CARE. If you or an eligible dependent are covered by this Plan and TRI-CARE, this Plan pays first and TRI-CARE pays second.

    No-fault Benefits. If a person covered by this Plan has a claim, which involves a motor vehicle accident covered by the"no-fault" insurance law of any state, health care expenses must be reimbursed first by the nofault insurance carrier. Only when the claimant has exhausted his or her health care benefits under the no-fault coverage will he or she be entitled to receive health care benefits under this Plan. If there are expenses for services that are covered under this Plan and which are not completely reimbursed by the no-fault carrier, such expenses may be reimbursed under this Plan, subject to the Plan's applicable maximums and other provisions. If you are covered for loss of earnings by any motor vehicle no-fault liability carrier, the disability benefits payable by this Plan will be reduced by any no-fault benefits available to you for loss of earnings.

    Other Coverage Provided By State or Federal Law. If you are covered by both this Plan and any other insurance provided by any other state or Federal law, the insurance provided by any other state or Federal law pays first and this Plan pays second.

    Workers' Compensation. This Plan does not provide benefits for expenses covered by Workers' Compensation or occupational disease laws. If an employer disputes the application of Workers' Compensation law for the illness or injury for which expenses are incurred, the Plan will pay benefits, subject to its right to recover those payments if and when it is determined that they are covered under a Workers' Compensation or occupational disease law (for information about subrogation and reimbursement of benefits, see pages 55-57).

    Your Disclosures To The Fund

    Everyone who is entitled to claim benefits from the Plan must furnish to the Fund all necessary information in writing as may be reasonably requested for the purpose of establishing, maintaining and administering the Plan. Failure to comply with such requests promptly and in good faith will be sufficient grounds for delaying or denying payment of benefits. The Board will be the sole judge of the standard of proof required in any case, and may periodically adopt such formulas, methods and procedures as the Board considers advisable.

    The information you give to the Fund, including statements concerning your age and marital status, affects the determination of your benefits. If any of the information you provide is false, you may be required to indemnify and repay the Fund for any losses or damages caused by your Health Fund - Suburban Plan for the School District of Philadelphia 55 false statements. In addition, if a claim has been submitted for payment or paid by the Fund as a result of false statements, the Fund may seek reimbursement and may elect to pursue the matter by pressing criminal charges. Knowingly claiming benefits for someone who is not eligible is considered fraud and could subject you to criminal prosecution.

    Subrogation and Reimbursement

    If another party or other source makes payments relating to a sickness or injury for which benefits have already been paid under the Plan, then the Fund is entitled to recover the amount of those benefits. You and your dependents may be required to sign a reimbursement agreement if you seek payment of medical expenses relating to the sickness or injury under the Plan before you have received the full amount you would recover through a judgment, settlement, insurance payment or other source. In addition, you and your dependents may be required to sign necessary documents and to promptly notify the Fund of any legal action.

    If you or your dependents are injured as a result of negligence or other wrongful acts, whether caused by you, your dependents, or by another party, and you or your dependents apply to this Fund for benefits and receive such benefits, this Fund shall then have a first priority lien for the full amount of those benefits should you recover any monies from any party that caused, contributed to or aggravated the injuries or from any other source otherwise responsible for payment thereof. This first priority lien applies whether these monies come directly from your own insurance company, another person or his or her insurance company, or any other source (including, but not limited to, any person, corporation, entity, uninsured motorist coverage, personal umbrella coverage, medical payments coverage, Workers' Compensation coverage, or no-fault automobile coverage, or any other insurance policy or plan).

    This lien arises through operation of the Plan. No additional subrogation or reimbursement agreement is necessary. The Fund's lien is a lien on the proceeds of any compromise, settlement, judgment and/or verdict received from any source.

    Any and all amounts received from any party or any other source by judgment, settlement, or otherwise, must be applied first to satisfy your reimbursement obligation to the Fund for the amount of medical expenses paid on your behalf or on your dependent's behalf. The Fund's lien is a lien of first priority for the entire recovery of funds paid on your behalf. Where the recovery from another party or any other source is partial or incomplete, the Fund's right to reimbursement takes priority over your or your dependent's right of recovery, regardless of whether or not you or 56 May 1, 2010 your dependent have been made whole for his or her injuries or losses. The Fund does not recognize and is not bound by any application of the "make whole" doctrine.

    The Board has the discretion to interpret any vague or ambiguous term or provision in favor of the Fund's subrogation or reimbursement rights.

    By applying for and receiving benefits under the Fund, you agree:

    • to restore to the Fund the full amount of the benefits that are paid to you and/or your dependents from the proceeds of any compromise, settlement, judgment and/or verdict, to the extent permitted by law
    • that the proceeds of any compromise, settlement, judgment and/or verdict received from another party, an insurance carrier or any other source, if paid directly to you (or to any other person or entity), will be held by you (or such other person or entity) in constructive trust for the Fund. (The same rules apply to any other person to whom you assign your rights.) The recipient of such proceeds is a fiduciary of the Fund with respect to such funds and is subject to the fiduciary provisions and obligations of ERISA. The Fund reserves the right to seek recovery from such person, entity or trust and to name such person, entity or trust as a defendant in any litigation arising out of the Fund's subrogation or reimbursement rights
    • that any lien the Fund may seek will not be reduced by any attorney fees, court costs or disbursements that you and/or your attorney might incur in an action to recover from another party or any other source, and these expenses may not be used to offset your obligation to restore the full amount of the lien to the Fund, and
    • that any recovery will not be reduced by and is not subject to the application of the common fund doctrine for the recovery of attorney's fees.

    We strongly recommend that if you are injured as a result of the negligence or wrongful act of another party, or if injuries resulted from your own acts, or the acts of your dependents, you should contact your attorney for advice and counsel. However, this Fund cannot and does not pay for your attorney fees. The Fund does not require you to seek any recovery whatsoever against another party or any other source, and if you do not receive any recovery, you are not obligated in any way to reimburse the Fund for any of the benefits that you applied for and accepted. However, in the event that you do not pursue any and all third parties or any other responsible sources, the Fund is authorized to pursue, sue, compromise or settle (at the Board's discretion) any such claims on your behalf and you agree to execute any and all documents necessary to pursue said claims, and you agree to fully cooperate with the Fund in the prosecution of any such claims.

    Should you seek to recover any monies from another party or any other source that caused, contributed to, aggravated your injuries, or is otherwise responsible, it is a rule of this Plan that you must give notice in writing of same to the Fund within ten days after either you or your attorney first attempt to recover such monies, or institute a lawsuit, or enter into settlement negotiations with another or take any other similar action. You must also cooperate with the Fund's reasonable requests concerning the Fund's subrogation and reimbursement rights and keep the Fund informed of any important developments in your action. You must also provide the Fund with any information or documents, upon request, that pertain to or are relevant to your actions. If litigation is commenced, you are required to give at least five days written notice to the Fund prior to any action to be taken as part of such litigation including, but not limited to, any pretrial conferences or other court dates. Representatives of the Fund reserve the right to attend such pretrial conferences or other court proceedings.

    In the event you fail to notify the Fund as provided for above, and/ or fail to restore to the Fund such funds as provided for above, the Fund reserves the right, in addition to all other remedies available to it by law or equity, to withhold or offset any other monies that might be due you or your dependents from the Fund for past or future claims, until such time as the Fund's lien is discharged and/or satisfied.

    For information about subrogation and any impact this may have on your health care claims, contact the Fund's subrogation administrator:

    Meridian Resource Company
    P.O. Box 2025
    Milwaukee, WI 53201-2025
    Fraud

    The Board reserves the right to cancel or rescind Fund coverage for any participant or enrolled dependent who willfully and knowingly engages in an activity intended to defraud the Fund. If a claim has been submitted for payment or paid by the Fund as a result of fraudulent representations, such as enrolling a dependent who is not eligible for coverage, the Fund will seek reimbursement and may elect to pursue the matter by pressing criminal charges.

    The Fund regularly evaluates claims to detect fraud or false statements. The Fund must be advised of any discounts or price adjustments made to you by any provider. A provider who waives or refunds co-payments is entering into a discount arrangement with you.

    The Fund calculates the benefit payment based on the amount actually charged, less any discounts, rebates, waivers, or refunds of co-payments or deductibles you receive. Failure to notify the Fund (through Member Services) of such price adjustments may result in an overpayment of benefits and constitutes a serious violation of the provisions of the Plan.

    Overpayments
    • If you (or your dependent or beneficiary) are overpaid for a claim, you (or your dependent or beneficiary) must return the overpayment. The Fund will have the right to recover any payments made that were based on false or fraudulent information, as well as any payments made in error. Amounts recovered may include interest and costs. If repayment is not made, the Fund may deduct the overpayment amount from any future benefits from this Fund that you or your dependent or beneficiary would otherwise receive or a lawsuit may be initiated to recover the overpayment.
    • If payment is made on your (or a dependent's) behalf to a hospital, doctor or other provider of health care and that payment is found to be an overpayment, the Fund will request a refund of the overpayment from the provider. If the refund is not received, the amount of the overpayment will be deducted from future benefits payable to the provider, or a lawsuit may be initiated to recover the overpayment.
    Continued Group Health Coverage

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    During a Family and Medical Leave

    The Family and Medical Leave Act (FMLA) allows up to 12 weeks of unpaid leave during any 12-month period due to:

    • the birth, adoption or placement with you for adoption of a child
    • providing care for a spouse, child or parent who is seriously ill, or
    • your own serious illness.

    Effective January 16, 2009, FMLA allows up to 12 weeks of leave for certain qualifying exigencies arising out of a covered military member's active duty status, or notification of an impending call or order to active duty status in support of a contingency operation.

    Effective January 28, 2008, FMLA allows up to 26 weeks of leave in a single 12-month period to care for a covered service member recovering from a serious injury or illness incurred in the line of duty on active duty. Eligible employees are entitled to a combined total of up to 26 weeks of all types of FMLA leave during the single 12-month period.

    During FMLA leave, you can continue all of your medical coverage and other benefits offered through the Plan. You are generally eligible for a leave under the FMLA if you:

  • have worked for the same contributing employer for at least 12 months
  • have worked at least 1,250 hours over the previous 12 months, and
  • work at a location where at least 50 employees are employed by the employer within 75 miles.
  • Check with your employer to determine if you are eligible for FMLA.

    The Fund will maintain the employee's eligibility status until the end of the leave, provided the contributing employer properly grants the leave under FMLA and the contributing employer makes the required notification and payment to the Fund. Of course, any changes in the Plan's terms, rules or practices that go into effect while you are away on leave apply to you and your dependents, the same as to active employees and their dependents. Call Member Services regarding coverage during FMLA leave.

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    During Military Leave

    If you are on active military duty for 31 days or less, you will continue to receive medical coverage in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). If you are on active duty for more than 31 days, USERRA permits you to continue medical coverage for you and your dependents at your own expense for up to 24 months provided you enroll for coverage. This continuation coverage operates in the same way as COBRA. (See pages 60-63 for information on COBRA.) In addition, your dependents may be eligible for health care under the Civilian Health & Medical Program of the Uniformed Services (TRI-CARE). This Plan will coordinate coverage with TRI-CARE (see page 54).

    When you return to work after receiving an honorable discharge, your full eligibility will be reinstated on the day you return to work with a participating employer, provided that you return to employment within one of the following time frames:

    • 90 days from the date of discharge if the period of military service was more than 180 days
    • 14 days from the date of discharge if the period of military service was 31 days or more, but less than 180 days
    • at the beginning of the first full regularly scheduled working period on the first calendar day following discharge (plus travel time and additional eight hours) if the period of service was less than 31 days.

    If you are hospitalized or convalescing from an injury resulting from active duty, these time limits may be extended for up to two years. Contact Member Services for more details.

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    Under COBRA

    Under a Federal law called the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), group health plans are required to offer temporary continuation of health coverage, on an employee-pay-all basis, in certain situations when coverage would otherwise end."Health coverage" includes the Fund's hospital, medical, behavioral health and substance abuse coverage.

    You do not have to prove that you are in good health to choose COBRA continuation coverage - but you do have to meet the Plan's COBRA eligibility requirements and you must apply for coverage. The Fund reserves the right to end your COBRA coverage retroactively if you are determined to be ineligible.

    If you are disabled and receiving (or are approved to receive) benefits under statutory short-term disability or Workers' Compensation under this Plan, the Plan provides coverage for up to 30 months as long as you remain disabled, are unable to work and you apply for coverage. If you are terminated by your employer and your termination is going to arbitration seeking reinstatement, the Plan provides coverage for up to six months. In these two cases of extended COBRA coverage, you do not have to pay the premium since it is paid by the Fund. Keep in mind that the maximum period that you have COBRA coverage is reduced by any period of time you received Fund-paid COBRA coverage.

    The following chart shows when you and your eligible dependents may qualify for continued coverage under COBRA, and how long your coverage may continue. Please keep in mind that the following information is a summary of the law and is therefore general in nature. If you have any questions about COBRA, please contact Member Services.

    Coverage May Continue For: If: Maximum Duration of Coverage:

    You and your eligible dependents

    Your covered employment terminates for reasons other than gross misconduct

    18 months

    You and your eligible dependents

    You become ineligible for coverage due to a reduction in your employment hours (e.g., leave of absence)

    18 months

    You and your eligible dependents

    You go on military leave 24 months

    Your dependents

    You die 36 months

    Your spouse and stepchild(ren)

    You legally separate, divorce or your marriage is civilly annulled 36 months

    Your dependent child(ren)

    Your dependent children no longer qualify as dependents 36 months

    Your dependents

    You terminate your employment or you reduce your work hours less than 18 months after the date of your Medicare (Part A or B or both) entitlement 36 months from the date of Medicare entitlement

    If you marry, have a newborn child or have a child placed with you for adoption while you are covered under COBRA, you may enroll that spouse or dependent child for coverage for the balance of the COBRA continuation period, on the same terms available to active participants. The same rules about dependent status and qualifying changes in family status that apply to active participants will apply to you and/or your dependent(s).

    FMLA leave. If you do not return to active employment after your FMLA leave of absence, you become eligible for COBRA continuation as a result of your termination of employment. For COBRA purposes, your employment is considered"terminated" at the end of the FMLA leave or the date that you give notice to your employer that you will not be returning to active employment, whichever happens first.

    Multiple Qualifying Events. If your dependents qualify for COBRA coverage in more than one way, they may be eligible for a longer continuation coverage period up to 36 months from the date they first qualified. For example, if you terminate employment, you and your enrolled dependents may be eligible for 18 months of continued coverage. During this 18-month period, if your dependent child stops being eligible for dependent coverage under the Plan (a second Qualifying Event), your child may be eligible for an additional period of continued coverage.

    The two periods combined cannot exceed a total of 36 months from the date of your termination (the first Qualifying Event). A second Qualifying Event may also occur if you become legally separated or divorced, or die.

    Continued coverage for up to 29 months from the date of the initial event may be available to those who, during the first 60 days of continuation coverage, become totally disabled within the meaning of Title II or XVI of the Social Security Act. This additional 11 months is available to you and your eligible dependents if notice of disability is provided to the Fund within 60 days after the Social Security determination of disability is issued and before the 18-month continuation period runs out. The cost of the additional 11 months coverage will increase to 150% of the full cost of coverage.

    To make sure you get all of the COBRA coverage you are entitled to, contact Member Services whenever something happens that makes you or your dependents eligible for COBRA coverage.

    Notifying the Fund of a Qualifying Event. Under the law, in order to have a right to elect COBRA coverage, you or your dependent are responsible for notifying Member Services of your legal separation or divorce, a child losing dependent status under the Plan, or if you become disabled (or you are no longer disabled) as determined by the Social Security Administration. You (or your family member) must notify Member Services in writing of any of these events no later than 60 days after the event occurs or 60 days after the date coverage would have been lost under the Plan because of that event, whichever is later. Your notice must include the following information:

    • name(s) of the individual(s) interested in COBRA continuation, and the relationship to the participant
    • date of the Qualifying Event, and
    • type of Qualifying Event (see the table of Qualifying Events on page 61).

    When your employer must notify the Fund. Your employer is responsible for notifying the Fund of your death, termination of employment or reduction in hours of employment. Your employer must notify the Fund of one of these Qualifying Events within 30 days after the date of the loss of coverage. Once notified, the Fund will send you a COBRA notice within 30 days.

    Making a COBRA election. Once the Fund is notified of your Qualifying Event, you will receive a COBRA notice and an election form. In order to elect COBRA, you or your dependent(s) must submit the COBRA election form to Member Services within 60 days after the date you would lose health coverage under the Fund or 60 days after the date of the COBRA notice, whichever is later.

    Each of your eligible dependents has an independent election right for COBRA coverage. This means that each dependent can decide whether or not to continue coverage under COBRA.

    Anyone who elects COBRA continuation coverage must promptly notify Member Services of address changes.

    Paying for COBRA coverage. If you or your dependents elect to continue coverage, you or they must pay the full cost of the coverage elected. The Fund is permitted to charge you the full cost of coverage for active employees and families plus an additional 2% (and up to an additional 50% for the 11-month disability extension). The first payment is due no later than 45 days after the election to receive coverage (and it will cover the period from the date you would lose coverage until the date of payment). Thereafter, payments are due on the first of each month and are considered to be on time if they are made within 30 days of the due date. Costs may change from year to year. Contact Member Services for more information about the cost of your COBRA coverage.

    If you fail to notify Member Services of your decision to elect COBRA continuation coverage or if you fail to make the required payment, your Plan coverage will end (and cannot be reinstated).

    What COBRA coverage provides. COBRA generally offers the same coverage that is made available to similarly situated employees or family members, but Life/AD&D and Disability Insurance are not available. If, during the period of COBRA continuation coverage, the Plan's benefits change for active employees, the same changes will apply to COBRA recipients.

    When COBRA coverage ends. COBRA coverage ordinarily ends after the maximum coverage period shown in the chart on page 61. It will stop before the end of the maximum period under any of the following circumstances:

    • A COBRA recipient fails to make the required COBRA contributions on time.
    • A COBRA recipient becomes enrolled in Medicare (Part A, B or both) after the date of the COBRA election, or becomes covered under another group plan that does not have a pre-existing conditions clause that affects the COBRA recipient's coverage.
    • Coverage has been extended for up to 29 months due to disability and there has been a final determination that the COBRA recipient is no longer disabled. The COBRA recipient must notify Member Services within 30 days of any such final determination.

    If COBRA is terminated prior to the end of the original period, you will be notified.

    Once your COBRA continuation coverage terminates for any reason, it cannot be reinstated.

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    Other Health Plan Information You Should Know

    Assignment of Plan Benefits

    You cannot assign or transfer benefits to anyone other than a health services provider (which you do by completing a claim form, which the provider of care will submit to the Plan, or by completing a form the Fund will provide). You cannot pledge the benefits owed to you for the purpose of obtaining a loan.

    Benefits or payments under the Plan are not otherwise assignable or transferable, except as the law requires. Benefits also are not subject to any creditor's claim or to legal process by any creditor of any covered individual, except under a Qualified Medical Child Support Order (QMCSO). A QMCSO is an order issued by a state court or agency that requires an employee to provide coverage under group health plans to a child.

    A QMCSO usually results from a divorce or legal separation. Whenever Member Services gets a QMCSO, its qualified status is carefully reviewed by the Fund in accordance with QMCSO procedures adopted by the Board and Federal law. For more information on QMCSOs, or to obtain a copy of the Plan's QMCSO procedures free of charge, contact the Fund's Compliance Office at the address on page 71.

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    No Liability for Practice of Medicine

    Neither the Fund, the Board nor any of their designees:

    • are engaged in the practice of medicine, nor do any of them have any control over any diagnosis, treatment, care or lack thereof, or any health care services provided or delivered to you by any health care provider, and
    • will have any liability whatsoever for any loss or injury caused to you by any health care provider by reason of negligence, by failure to provide care or treatment, or otherwise.

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    Privacy of Protected Health Information

    The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that imposes certain confidentiality and security obligations on the Fund with respect to medical records and other individually identifiable health information used or disclosed by the Fund. HIPAA also gives you rights with respect to your health information, including certain rights to receive copies of the health information that the Health Fund - Suburban Plan for the School District of Philadelphia 65 Fund maintains about you, and knowing how your health information may be used. A complete description of how the Fund uses your health information, and your other rights under HIPAA's privacy rules is available in the Fund's "Notice of Privacy Practices," which is distributed to all named participants. Anyone may request an additional copy of this Notice by contacting the Compliance Office at the address on page 71.

    In April 2003, the Fund's Board of Trustees adopted certain HIPAA privacy and security language that requires the Board of Trustees, in its role as Plan Sponsor of the Fund, to keep your health information private and secure. Any questions you may have about HIPAA may be directed to the Compliance Office at the address on page 71.

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    Certificate of Creditable Coverage

    If you lose medical coverage, the Fund will issue you a Certificate of Creditable Coverage free of charge showing how long you were covered under this Plan. This Certificate enables you to receive credit toward any pre-existing condition exclusion under a new group plan or insurance policy.

    This Certificate is available to you upon request by contacting Member Services at any point while you are covered under the Plan and up to 24 months after coverage ceases.

    Please be advised that in any event, you will also automatically be provided with a Certificate of Creditable Coverage from the Fund and Empire when you lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage or when your COBRA continuation coverage ceases.

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    Converting to Individual Coverage

    Life Insurance. After your group life insurance under the Plan ends, you may convert it to an individual life insurance policy, as long as you apply for converted coverage within:

    • 31 days from the date benefits were terminated, or
    • 45 days from the date notice is given, if notice is given more than 15 days but less than 90 days after the date benefits were terminated.

    (This time period is separate and apart from the Plan's COBRA provisions.)

    You may convert your group coverage only to a Whole Life, Universal Life or One-Year Non-Renewable Term policy. The amount converted to an individual policy cannot be more than the $25,000 you had under the group Plan. Your individual policy will become effective 61 days after the termination of your coverage. Group life insurance protection continues in force, however, during the applicable period cited above, whether or not you exercise the conversion option. Contact MetLife for more information about converting life insurance.

    All Other Plan Benefits. You cannot convert hospital, medical, behavioral health and substance abuse or AD&D benefits to individual coverage.

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    General Information

    Employer Contributions

    The Plan receives contributions in accordance with collective bargaining agreements between the Realty Advisory Board on Labor Relations, Inc., or various independent employers, and your union. These collective bargaining agreements provide that employers contribute to the Fund on behalf of each covered employee. Employers that are parties to such collective bargaining agreements may also participate in the Fund on behalf of non-collectively bargained employees, if approved by the Trustees, by signing a participation agreement. Certain other employers (such as Local 32BJ itself and the 32BJ Benefit Funds) participate in the Fund on behalf of their employees by signing a participation agreement.

    The Compliance Office will provide you, upon written request, with information as to whether a particular employer is contributing to the Fund on behalf of participants working under a collective bargaining agreement or participation agreement and, if so, to which Plan the employer is contributing.

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    How Benefits May Be Reduced, Delayed or Lost

    There are certain situations under which benefits may be reduced, delayed or lost. Most of these circumstances are spelled out in this booklet, but benefit payments also may be affected if you, your beneficiary or your provider of services, as applicable, do not:

    • file a claim for benefits properly or on time
    • furnish the information required to complete or verify a claim
    • have a current address on file with Member Services
    • cash checks within eighteen (18) months of the date issued

    You should also be aware that Plan benefits are not payable for enrolled dependents who become ineligible due to age, marriage, divorce or legal separation (unless they elect and pay for COBRA benefits, as described on pages 60-63).

    If the Plan mistakenly pays more than you are eligible for, or pays benefits that were not authorized by the Plan, the Fund may seek any permissible remedy allowed by law to recover benefits paid in error (also see"Overpayments," page 58 and"Subrogation," pages 55-57).

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    Compliance with Federal Law

    The Plan is governed by regulations and rulings of the Internal Revenue Service and the Department of Labor, and current tax law. The Plan will always be construed to comply with these regulations, rulings and laws. Generally, Federal law takes precedence over state law.

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    Plan Amendment or Termination

    The Board intends to continue the Plan indefinitely, but reserves the right to amend or terminate it in its sole discretion. If the Plan is terminated or otherwise amended, it will not affect your right to receive reimbursement for eligible expenses you have incurred prior to termination or amendment.

    Upon a full termination of the Plan, Plan assets will be applied to provide benefits in accordance with the applicable provisions of the Trust Agreement and Federal law.

    Keep in mind that the benefits provided under the Plan are not vested. This is true for retirees, as well as active employees. Therefore, at any time the Board can end or amend benefits, including retiree benefits, in its sole and absolute discretion.

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    Plan Administration

    The Plan is what the law calls a"health and welfare" benefits program. Benefits are provided from the Fund's assets. Those assets are accumulated under the provisions of the Trust Agreement and are held in a Trust Fund for the purpose of providing benefits to covered participants and dependents and defraying reasonable administrative expenses.

    The Plan is administered by the Board of Trustees. The Board governs this Plan in accordance with an Agreement and Declaration of Trust. The Board and/or its duly authorized designee(s) has the exclusive right, power and authority, in its sole and absolute discretion, to administer, apply and interpret the Plan established under the Trust Agreement, and to decide all matters arising in connection with the operation or administration of the Plan established under the Trust. Without limiting the generality of the foregoing, the Board and/or its duly authorized designees, including the Appeals Committee with regard to benefit claim appeals, shall have the sole and absolute discretionary authority to:

    • take all actions and make all decisions with respect to the eligibility for, and the amount of, benefits payable under the Plan
    • formulate, interpret and apply rules, regulations and policies necessary to administer the Plan in accordance with the terms of the Plan
    • decide questions, including legal or factual questions, relating to the calculation and payment of benefits under the Plan
    • resolve and/or clarify any ambiguities, inconsistencies and omissions arising under the Plan, as described in this SPD, the Trust Agreement or other Plan documents
    • process and approve or deny benefit claims and rule on any benefit exclusions, and
    • determine the standard of proof required in any case.

    All determinations and interpretations made by the Board and/or its duly authorized designee(s) shall be final and binding upon all participants, eligible dependents, beneficiaries and any other individuals claiming benefits under the Plan.

    The Board has delegated certain administrative and operational functions to the Fund staff, other organizations and to the Appeals Committee. Most of your day-to-day questions can be answered by Member Services staff. If you wish to contact the Board, please write to:

    Board of Trustees
    Building Service 32BJ Health Fund
    101 Avenue of the Americas
    New York, NY 10013-1991

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    Statement of Rights under the Employee Retirement Income Security Act of 1974 as Amended

    As a participant in the Building Service 32BJ Health Fund, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be entitled to:

    • Examine, without charge, at the Compliance Office, all documents governing the Plan, including insurance contracts, collective bargaining agreements, participation agreements and the latest annual report (Form 5500 series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration ("EBSA").
    • Obtain, upon written request to the Compliance Office, copies of documents governing the operation of the Plan, including insurance contracts, collective bargaining agreements, participation agreements, the latest annual report (Form 5500 series) and an updated Summary Plan Description.
    • Receive a summary of the Plan's annual financial report. The Board is required by law to furnish each participant with a copy of this summary annual report.
    • Continue Group Health Coverage. You may continue group health coverage for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a Qualifying Event. You or your dependents may have to pay for such coverage. See pages 60-63 for information about COBRA. If you change medical plans and wish to have any pre-existing conditions covered, you will need a Certificate of Creditable Coverage. You can get this free of charge from your group health plan or health insurance company when you lose coverage, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your new coverage.

    In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the Plan. The people who operate your Plan, called"fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.

    If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

    Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.

    If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court after you have exhausted the Plan's appeal process. If it should happen that Fund fiduciaries misuse the Fund's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in Federal court. You may not file a lawsuit until you have followed the appeal procedures described on pages 47-51. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees; for example, if it finds your claim is frivolous.

    If you have any questions about your Plan, you should contact the Plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan administrator, you should contact the nearest office of EBSA, U.S. Department of Labor, listed in your telephone directory, or the:

    Division of Technical Assistance and Inquiries
    Employee Benefits Security Administration (EBSA)
    U.S. Department of Labor
    200 Constitution Avenue N.W.
    Washington, DC 20210

    You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of EBSA or by visiting the Department of Labor's website: http://www.dol.gov.

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    Plan Facts

    This Summary Plan Description is the formal plan document for the Suburban Plan for the School District of Philadelphia of the Health Fund.

    Plan Name: Building Service 32BJ Health Fund
    Employer Identification Number: 13-2928869
    Plan Number: 501
    Plan Year: July 1 - June 30
    Type of Plan: Welfare Plan

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    Funding of Benefits and Type of Administration

    Self funded. All contributions to the Trust Fund are made by contributing employers under the Plan in accordance with their written agreements. Benefits are administered by the administrative contacts listed on page 49.

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    Plan Sponsor and Administrator

    The Plan is administered by a joint Board of Trustees consisting of Union Trustees and Employer Trustees. The office of the Board may be contacted at:

    Board of Trustees
    Building Service 32BJ Health Fund
    101 Avenue of the Americas
    New York, NY 10013-1991

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    Participating Employers

    The Compliance Office will provide you, upon written request, with information as to whether a particular employer is contributing to the Plan on behalf of employees working under a written agreement, as well as the address of such employer. Additionally, a complete list of employers and unions sponsoring the Plan may be obtained upon written request to the Compliance Office and is available for examination at the Compliance Office.

    To contact the Compliance Office, write to:

    Compliance Office
    Building Service 32BJ Benefit Funds
    101 Avenue of the Americas
    New York, NY 10013-1991

    To contact the Health Fund, call:

    1-212-388-3500

    or write to:

    Building Service 32BJ Health Fund
    101 Avenue of the Americas
    New York, NY 10013-1991

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    Agent for Service of Legal Process

    The Board has been designated as the agent for the service of legal process. Legal process may be served at the Compliance Office or on the individual Trustees. For disputes arising under the portion of the Plan insured by MetLife, service of legal process may be made upon MetLife at their local offices or upon the supervisory official of the Insurance Department of the state in which you reside.

    Glossary

    Allowed Amount

    means the maximum the Fund will pay for a covered service. When you go in-network, the allowed amount is based on an agreement with the provider. When you go out-of-network, the allowed amount is based on the Fund's payment rate of allowed charges to a network provider.

    Ambulette

    means ground transportation to or from a licensed medical facility when arranged by the Plan's Medical Management Department. This is covered only as a home health care expense, meaning you need to be eligible for home health care in order to receive coverage for the ambulette.

    Co-insurance

    means the 30% you pay toward eligible out-of-network medical expenses.

    Contributing employer

    (or employer ) is a person, company or other employing entity that has signed a collective bargaining agreement or participation agreement with the union or trust, and the agreement requires contributions to the Health Fund for work in covered employment.

    Co-payment

    means the flat-dollar fee you pay for office visits and certain covered services when you use providers. The Plan then pays 100% of remaining covered expenses.

    Covered employment

    means work in a classification for which your employer is required to make contributions to the Fund.

    Covered services

    are the services for which the Fund provides benefits under the terms of the Plan.

    Deductible

    means the dollar amount you must pay each calendar year before benefits become payable for covered out-of-network services.

    Doctor

    means a licensed and qualified provider (M.D., D.O., D.C., or D.P.M.) who is authorized to practice medicine, perform surgery and/or prescribe drugs under the laws of the state or jurisdiction where the services are rendered, acts within the scope of his or her license and is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient.

    Emergency

    means a condition whose symptoms are so serious that someone who is not a doctor but who has average knowledge of health and medicine could reasonably expect that, without immediate medical attention, the following would happen:

    • the patient's health would be placed in serious jeopardy
    • there would be serious problems with the patient's body functions, organs or parts
    • there would be serious disfigurement or
    • the patient or those around him or her would be placed in serious jeopardy, in the event of a behavioral health emergency.

    Severe chest pains, extensive bleeding and seizures are examples of emergency conditions.

    In-network

    benefits are benefits for covered services delivered by providers and suppliers who have contracted with the Fund, Empire, MHN or with any other administrators under contract to the Fund, to provide services and supplies at a pre-negotiated rate. Services provided must fall within the scope of their individual professional licenses.

    Medically necessary

    , as determined by the applicable insurance carrier or the Fund, means services, supplies or equipment that satisfy all of the following criteria:

    • are provided by a doctor, hospital or other provider of health services
    • are consistent with the symptoms or diagnosis and treatment of an illness or injury; or are preventive in nature, such as annual physical examinations, well-woman care, well-child care and immunizations, and are specified by the Plan as covered
    • are not experimental, except as specified otherwise in this booklet
    • meet the standards of good medical practice
    • meet the medical and surgical appropriateness requirements established under Empire BlueCross BlueShield medical policy guidelines
    • provide the most appropriate level and type of service that can be safely provided to the patient
    • are not solely for the convenience of the patient, the family or the provider
    • are not primarily custodial

    The fact that a network provider may have prescribed, recommended or approved a service, supply or equipment does not, in itself, make it medically necessary.

    For behavioral health purposes, medically necessary is subject to additional conditions. See pages 33-40 for information.

    Mental disorder

    means a mental or nervous condition that meets all of the following conditions:

    • it is a clinically significant behavioral or psychological syndrome or pattern
    • it is associated with a painful symptom, such as distress
    • it impairs a patient's ability to function in one or more major life activities and
    • it is a condition listed as an Axis I disorder (excluding V Codes) in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association.

    Network

    means the same as in-network.

    Out-of-Network

    provider/supplier means a doctor, other professional provider, or durable medical equipment, home health care or home infusion supplier who is not in the Plan's network for medical/ hospital or behavioral health and substance abuse services. Out-of-network benefits are benefits for covered services provided by out-of- network providers and suppliers.

    Participating provider

    means a provider that has agreed to provide services, treatment and supplies at a pre-negotiated rate.

    TRI-CARE

    (formerly CHAMPUS) is the health services and support program for U.S. Military Personnel on active duty, U.S. Military retirees, and their families.

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    Footnotes

    1 Hospital/facility is a fully licensed acute-care general facility that has all of the following on its own premises:

    • a broad scope of major surgical, medical, therapeutic and diagnostic services available at all times to treat almost all illnesses, accidents and emergencies
    • 24-hour general nursing service with registered nurses who are on duty and present in the hospital at all times
    • a fully staffed operating room suitable for major surgery, together with anesthesia service and equipment (the hospital must perform major surgery frequently enough to maintain a high level of expertise with respect to such surgery in order to ensure quality care)
    • assigned emergency personnel and a crash cart to treat cardiac arrest and other medical emergencies
    • diagnostic radiology facilities
    • a pathology laboratory and
    • an organized medical staff of licensed doctors.

    For pregnancy and childbirth services, the definition of hospital includes any birthing center that has a participation agreement with either Empire or, for PPO participants, another BlueCross and/or BlueShield plan.

    For physical therapy purposes, the definition of a hospital may include a rehabilitation facility either approved by Empire or participating with Empire or, for PPO participants, another BlueCross and/or BlueShield plan other than specified above.

    For kidney dialysis treatment, covered in-network only for treatment started after 4/5/07, a facility in New York State qualifies for in-network benefits if the facility has an operating certificate issued by the New York State Department of Health, and participates with Empire or another BlueCross and/or BlueShield plan. In other states, the facility must participate with another BlueCross and/or BlueShield plan and be certified by the state using criteria similar to New York's. Out-of-network benefits will be paid only for non-participating facilities that have an appropriate operating certificate.

    For certain specified benefits, the definition of a hospital or facility may include a hospital, hospital department or facility that has a special agreement with Empire.

    Empire does not recognize as hospitals: nursing or convalescent homes and institutions; rehabilitation facilities (except as noted above), institutions primarily for rest or for the aged, spas, sanitariums, infirmaries at schools, colleges or camps; and any institution primarily for the treatment of drug addiction, alcoholism or behavioral care.

    2 Outpatient surgery includes hospital surgical facilities, surgeons and surgical assistants; chemotherapy and radiation therapy, including medications, in a hospital outpatient department, doctor's office or facility (medications that are part of outpatient hospital treatment are covered if they are prescribed by the hospital and filled by the hospital pharmacy). Same-day, ambulatory or outpatient surgery (including invasive diagnostic procedures) means surgery that does not require an overnight stay in a hospital and:

    • is performed in a same-day or hospital outpatient surgical facility
    • requires the use of both surgical operating and postoperative recovery rooms
    • does not require an inpatient hospital admission, and
    • would justify an inpatient hospital admission in the absence of a same-day surgery program.

    3 Kidney dialysis treatment (including hemodialysis and peritoneal dialysis) covered in-network only for treatment started after 4/5/07, is covered in the following settings until Medicare becomes primary for end-stage renal disease dialysis (which occurs after 30 months):

    • at home, when provided, supervised and arranged by a doctor and the patient has registered with an approved kidney disease treatment center (not covered: professional assistance to perform dialysis and any furniture, electrical, plumbing or other fixtures needed in the home to permit home dialysis treatment) or
    • in a hospital-based or free-standing facility.

    4 Skilled nursing facility means a licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Skilled nursing facilities are useful when you do not need the level of care a hospital provides, but you are not well enough to recover at home. The Plan covers inpatient care in a skilled nursing facility, for up to 60 days of inpatient care per person per year. However, you must use an in-network facility and your doctor must provide a referral and written treatment plan, a projected length of stay and an explanation of the needed services and the intended benefits of care. Care must be provided under the direct supervision of a doctor, registered nurse, physical therapist or other health care professional.

    5 Hospice care is for patients who are diagnosed as terminally ill (that is, they have a life expectancy of six months or less). Up to 210 days of hospice care is covered in full in-network only; there are no out-of-network hospice benefits. The Plan covers hospice services when the patient's doctor certifies that the patient is terminally ill and the hospice care is provided by a hospice organization certified by the state in which the hospice organization is located. Hospice care services include:

    • up to 12 hours a day of intermittent nursing care by an RN or LPN
    • medical care by the hospice doctor
    • drugs and medications prescribed by the patient's doctor that are not experimental and are approved for use by the most recent Physicians' Desk Reference
    • approved drugs and medications
    • physical, occupational, speech and respiratory therapy when required
    • lab tests, X-rays, chemotherapy and radiation therapy
    • social and counseling services for the patient's family, including bereavement counseling visits for up to one year following the patient's death (if eligible)
    • medically necessary transportation between home and hospital or hospice
    • medical supplies and rental of durable medical equipment, and
    • up to 14 hours of respite care a week.

    6 Home health caremeans services and supplies including nursing care by a registered nurse (RN) or licensed practical nurse (LPN) and home health aid services. The Plan covers up to 200 home health care visits per person per year (in-network and out-ofnetwork combined), as long as your doctor certifies that home health care is medically necessary and approves a written treatment plan. Up to four hours of care by an RN, a home health aide or a physical therapist count as one home health care visit. Benefits are payable for up to three visits a day. Home health care services include:

    • part-time nursing care by an RN or LPN
    • part-time home health aid services
    • restorative physical, occupational or speech therapy
    • medications, medical equipment and medical supplies prescribed by a doctor
    • laboratory tests, and
    • ambulette service when arranged by the Plan's Medical Management Department.

    If you use a home health care agency in the Empire Direct POS network, the agency is responsible for calling Health Services to pre-certify. If you use an out-of-network home health care agency, you are responsible for calling; otherwise, a pre-certification penalty will apply.

    7 Home infusion therapya service sometimes provided during home health care visits, is available only in-network. The network provider must pre-certify by calling the Health Services Program. An Empire Direct POS network home health care agency or home infusion supplier may not bill you for covered services. If you receive a bill from one of these providers, contact Member Services.

    8 Emergency room treatment benefits are limited to the initial visit for emergency care. An in-network provider (not an emergency room of a participating hospital) must provide all follow-up care for you to receive maximum benefits. Also remember to contact the Medical Management Department at the phone number on the back of your Empire ID card within 48 hours after an emergency hospital admission, as described on pages 2023, to precertify any continued stay in the hospital. If you have an emergency outside the Empire BlueCard Plan Area (see page 19), show your Empire ID Card at the emergency room. If the hospital participates with another BlueCross and/or BlueShield program, your claim will be processed by the local BlueCross plan. If it is a non-participating hospital, you will need to file a claim in order to be reimbursed for your eligible expenses.

    9 Ambulance Services (land and air) are covered in an emergency and in other situations when it is medically appropriate (such as taking a patient home when the patient has a major fracture or needs oxygen during the trip home). Air ambulance is covered when the patient's medical condition is such that the time needed to transport by land poses a threat to the patient's survival or seriously endangers the patient's health or the patient's location is such that accessibility is only feasible by air transportation; and the patient is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life threatening. Life threatening medical conditions include, but are not limited to, the following:

    • Intracranial bleeding
    • Cardiogenic shock
    • Major burns requiring immediate treatment in a Burn Center
    • Conditions requiring immediate treatment in a Hyberbaric Oxygen Unit
    • Multiple severe injuries
    • Transplants
    • Limb-threatening trauma
    • High risk pregnancy, and
    • Acute myocardial infarction; if this would enable the patient to receive a more timely medically necessary intervention (such as PTCA or fibrinolytic therapy).

    10 Second surgical opinions are covered under the Plan. When you secure a second opinion from a participating provider, you are responsible only for the appropriate copayment. Should you secure a second opinion from a non-participating provider, you are responsible for any deductibles and coinsurances required under the Plan, as well as charges that exceed the Plan's allowed amount.

    11 Diabetes coverage includes diet information, management and supplies (such as blood glucose monitors, testing strips and syringes) prescribed by an authorized provider.

    12 Preventive care under the Plan includes routine physicals, subject to limits shown on page 25. Eligible expenses include X-rays, laboratory or other tests given in connection with the exam and materials for immunizations for infectious diseases. Adults are covered for immunizations if medically necessary.

    13 Well-child care covers visits to a pediatrician, family practice doctor, nurse or licensed nurse practitioner. Regular checkups may include a physical examination, medical history review, developmental assessment, guidance on normal childhood development and laboratory tests. The tests may be performed in the office or a laboratory and must be within five days of the doctor's office visit. The number of well-child visits covered per year depends on your child's age, as shown in the chart on page 25. Covered immunizations include: Diphtheria, tetanus and pertussis (DtaP), Hepatitis B, Haemophilus influenza Type B (Hib), Pneumococcus (Pcv), Polio (IPV), Measles, mumps and rubella (MMR), Varicella (chicken pox), Tetanus-diphtheria (Td), Hepatitis A & influenza, HPV, Rotavirus, Meningococcal polysaccharide and conjugate, other immunizations as determined by the American Academy of Pediatrics, Superintendent of Insurance and the Commissioner of Health in New York State or the state where your child lives.

    14 Services of a certified nurse-midwife are covered if she or he is affiliated with, or practicing in conjunction with, a licensed facility and the services are provided under qualified medical direction.

    15 Pre-planned home delivery of a child by a certified nurse-midwife is a covered service. The reimbursement rate for this service is at the contracted Empire BlueCross BlueShield Direct Point-of-Service (Direct POS) Obstetrician/Gynecologist global rate.

    16 Physical therapy is covered for up to 30 days of covered inpatient physical therapy per person per year (in-network and out-of-network combined). Physical therapy, physical medicine and rehabilitation services or any combination of these are covered as long as the treatment is prescribed by your doctor and designed to improve or restore physical functioning within a reasonable period of time. If you receive therapy on an inpatient basis, it must be short term. Occupational, speech and vision therapy are covered if prescribed by your doctor and provided by a licensed therapist (occupational, speech or vision, as applicable) in your home, in a therapist's office or in an approved outpatient facility.

    Up to 30 outpatient visits are covered per year for physical therapy. Speech, vision and occupational therapy combined are covered for up to 30 visits per year. You must receive any such services through a network provider in the home, office or the outpatient department of a network facility. For outpatient physical therapy, you must pre-certify from the first visit.

    17 Durable medical equipment and supplies means buying, renting and/or repairing prosthetics (such as artificial limbs), orthotics and other durable medical equipment and supplies but you generally must go in-network for them. The only exceptions are glucometers and disposable medical supplies, such as syringes, which are covered up to the allowed amount whether you get them from an in-network or out-of-network supplier. In addition to the items listed above, the Plan covers:

    • prosthetics/orthotics and durable medical equipment from suppliers, when prescribed by a doctor and approved by the Health Services Program, including:
      artificial arms, legs, eyes, ears, nose, larynx and external breast prostheses
      supportive devices essential to the use of an artificial limb
      corrective braces
      wheelchairs, hospital-type beds, oxygen equipment, sleep apnea monitors
      replacement of covered medical equipment because of wear, damage, growth or change in patient's need, when ordered by a doctor
      reasonable cost of repairs and maintenance for covered medical equipment.

    The network supplier must pre-certify the rental or purchase of durable medical equipment. In addition, the Plan will cover the cost of buying equipment when the purchase price is expected to be less costly than long term rental, or when the item is not available on a rental basis.

    18 Nutritional supplements include enteral formulas, which are covered if the patient has a written order from a doctor that states the formula is medically necessary and effective, and that without it the patient would become malnourished, suffer from serious physical disorders or die. Modified solid-food products will be covered for the treatment of certain inherited diseases if the patient has a written order from a doctor.

    19 Cosmetic Surgery will be considered not medically necessary unless it is necessitated by injury, is for breast reconstruction after cancer surgery, or is necessary to lessen a disfiguring disease or a deformity arising from, or directly related to, a congenital abnormality. Cosmetic treatment includes any procedure that is directed at improving the patient's appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or disease.

    20 Experimental or investigative means treatment that, for the particular diagnosis or treatment of the enrolled person's condition, is not of proven benefit and not generally recognized by the medical community (as reflected in published literature). Government approval of a specific technology or treatment does not necessarily prove that it is appropriate or effective for a particular diagnosis or treatment of an enrolled person's condition. A claims administrator may require that any or all of the following criteria be met to determine whether a technology, treatment, procedure, biological product, medical device or drug is experimental, investigative, obsolete or ineffective:

    • there is final market approval by the U.S. Food and Drug Administration (FDA) for the patient's particular diagnosis or condition, except for certain drugs prescribed for the treatment of cancer; once the FDA approves use of a medical device, drug or biological product for a particular diagnosis or condition, use for another diagnosis or condition may require that additional criteria be met
    • published peer-reviewed medical literature must conclude that the technology has a definite positive effect on health outcomes
    • published evidence must show that over time the treatment improves health outcomes (i.e., the beneficial effects outweigh any harmful effects)
    • published proof must show that the treatment at the least improves health outcomes or that it can be used in appropriate medical situations where the established treatment cannot be used. Published proof must show that the treatment improves health outcomes in standard medical practice, not just in an experimental laboratory setting.

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    Contact Information

    ALERT: 5/22/13 NEW Click here for important benefit changes>>


    What do you need? Who to contact How
    • General Information about your eligibility and benefits
    • Information on your hospital and medical benefits

    ALERT: 5/22/13 NEW Click here for important benefit changes>>

    Member Services Call 1-800-551-3225
    8:30 am - 5:00 pm
    Monday - Friday or

    Visit the walk-in center at
    101 Avenue of the Americas
    8:00 am - 5:30 pm
    Monday - Friday
    • To find a primary care physician
    • To find participating Empire providers

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    Member Services

    Call 1-800-551-3225 or
    Visit www.empireblue.com
    (for Empire Hospital/Medical only)

    • Information about your life insurance plan

    Metlife

    Call 1-866-492-6983
    Visit https://mybenefits.metlife.com

    Empire

    Call 1-866-230-3225
    • To help prevent or report health insurance fraud (medical or hospital)

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    Empire Fraud Hotline

    Call Call 1-800-423-7283
    9:00 am - 5:00 pm
    Monday - Friday
    • Immediate medical advice

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    Nurses Healthline

    Call 1-877-825-5276
    24 hours a day/7 days a week
    • Help with family and personal problems like depression, alcohol and substance abuse, divorce, etc.

    ALERT: 5/22/13 NEW Click here for important benefit changes>>

    MHN for behavioral health services

    Call 1-800-798-2150

    The Trustees believe the Suburban Plan for the School District of Philadelphia is a"grandfathered health plan" under the Patient Protection and Affordability Act (the Affordable Care Act). Being a grandfathered health plan means that your plan does not include certain consumer protections of the Affordable Care Act. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at 1-212-388-3500 or 1-800-551-3225 (outside the 5 NYC boroughs). You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or visit www.dol.gov/ebsa.

    Building Service 32BJ Benefit Funds
    25 West 18th Street, New York, NY 10011
    Tel: 800.551.3225