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DISCLOSURE BROCHURE for NEVADA INDIVIDUAL BASIC PLAN Aetna Health Inc. 7720 North16th Street Suite 400 Phoenix, AZ 85020 Phone number: (602) 427-2200 This disclosure brochure is to be made available to each individual prior to purchase of this plan. The disclosure brochure consists of a sample Certificate of Coverage and Schedule of Benefits. This brochure is only a summary of the terms and conditions of the plan. The Group Agreement, Certificate of Coverage and Schedule of Benefits should be consulted to determine the governing contractual provisions of the Plan. Under the Aetna plan, usual and customary is referred to as reasonable charge, which is defined in the attached sample Certificate of Coverage on page 28. The Exclusions and Limitations Section of the Certificate of Coverage begins on page 10. Individuals have the right to renew this plan annually except under the following circumstances: 1. Aetna Health, Inc. discontinues transacting insurance in Nevada, or in the geographic area where the individual is located, in accordance with all statutory requirements; 2. The individual fails to pay the premiums or contributions required by the terms of this plan; 3. The individual misrepresents any information regarding the members covered under this plan or other information regarding eligibility for coverage under this plan; 4. The individual commits a fraudulent act to obtain or maintain coverage under the plan. Additional information regarding termination of coverage may be found in the Certificate of Coverage starting on page 13. www.aetna.com 01.28.304.1-NV (7/05) DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN AETNA HEALTH, INC. (NEVADA) INDIVIDUAL CONVERSION CERTIFICATE OF COVERAGE This is an Individual Conversion Certificate of Coverage (hereinafter referred to as “Certificate”) between Aetna, hereinafter referred to as HMO, and the Contract Holder. This Certificate determines the terms and conditions of coverage. Provisions of this Certificate include the Enrollment Form, Schedule of Benefits, and any amendments or endorsements. Amendments or endorsements may be delivered with the Certificate or added thereafter. E L P M A S If any provision of this Certificate is deemed to be invalid or illegal, such provision shall be fully severable and the remaining provisions of this Certificate shall continue in full force and effect. In consideration of the Premium payments made by or on behalf of the Contract Holder, HMO shall provide coverage for those services described in this Certificate subject to the terms and conditions set forth in this Certificate. HMO agrees with the Contract Holder to provide coverage for benefits, in accordance with the conditions, rights, and privileges as set forth in this Certificate. Members covered under this Certificate are subject to all the conditions and provisions of this Certificate. This Certificate describes covered health care benefits. Coverage for services or supplies is provided only if it is furnished while an individual is a Member. This means that coverage is provided only for health care services furnished while this coverage is in force. Except as shown in the Continuation and Conversion section of this Certificate, coverage is not provided for any services received before coverage starts or after coverage ends. Certain words have specific meanings when used in this Certificate. The defined terms appear in bold type with initial capital letters. The definitions of those terms are found in the Definitions section of this Certificate. This Certificate is not in lieu of insurance for Worker’s Compensation. This Certificate is governed by applicable federal law and the laws of the State of Nevada. READ THIS ENTIRE CERTIFICATE CAREFULLY. IT DESCRIBES THE RIGHTS AND OBLIGATIONS OF MEMBERS AND HMO. IT IS THE CONTRACT HOLDER’S AND THE MEMBER’S RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CERTIFICATE. MEMBERS WITH QUESTIONS REGARDING OF THE TERMS OR CONDITIONS DESCRIBED HEREIN MAY CALL HMO AT THE 800 NUMBER LISTED ON THEIR ID CARD. THE NEVADA DIVISION OF INSURANCE PROVIDES A TOLL FREE TELEPHONE NUMBER WHICH NEVADA CONSUMERS MAY USE FOR INQUIRIES AND COMPLAINTS REGARDING HEALTH PLANS. --1-888-872-3234 -- HOURS OF OPERATION --- 8AM TO 5PM WEEKDAYS IN SOME CIRCUMSTANCES, CERTAIN MEDICAL SERVICES ARE NOT COVERED OR MAY REQUIRE PREAUTHORIZATION BY HMO. NO SERVICES ARE COVERED UNDER THIS CERTIFICATE IN THE ABSENCE OF PAYMENT OF CURRENT PREMIUMS SUBJECT TO THE 31-DAY GRACE PERIOD AND THE PREMIUMS SECTION OF THIS CERTIFICATE. THIS CERTIFICATE APPLIES TO COVERAGE ONLY AND DOES NOT RESTRICT A MEMBER’S ABILITY TO RECEIVE HEALTH CARE SERVICES THAT ARE NOT, OR MIGHT NOT BE, COVERED BENEFITS UNDER THIS CERTIFICATE. NO PARTICIPATING PROVIDER OR OTHER PROVIDER, INSTITUTION, FACILITY OR AGENCY IS AN AGENT OR EMPLOYEE OF HMO. HMO/NV INDDISCBASIC 3/99 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN TABLE OF CONTENTS Section Page HMO Procedure 1 Eligibility and Enrollment 2 Covered Benefits E L P M A S 4 Exclusions and Limitations 10 Termination of Coverage 13 Continuation 14 Grievance Procedure 15 Coordination of Benefits 18 Responsibility of Members 21 General Provisions 21 Premiums Definitions HMO/NV INDDISCBASIC 3/99 25 25 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN HMO PROCEDURE A. Selecting a Participating Primary Care Physician. At the time of enrollment, each Member should select a Participating Primary Care Physician (PCP) from HMO’s Directory of Participating Providers to access Covered Benefits as described in this Certificate. The choice of a PCP is made solely by the Member. If the Member is a minor or otherwise incapable of selecting a PCP, the Subscriber should select a PCP on the Member’s behalf. Until a PCP is selected, benefits will be limited to coverage for Medical Emergency care. E L P M A S B. The Primary Care Physician. The PCP coordinates a Member’s medical care, as appropriate, either by providing treatment or by issuing Referrals to direct the Member to a Participating Provider. The PCP can also order lab tests and x-rays, prescribe medicines or therapies, and arrange hospitalization. Except in a Medical Emergency or for certain direct access Specialist benefits as described in this Certificate, only those services which are provided by or referred by a Member’s PCP will be covered. Covered Benefits are described in the Covered Benefits section of this Certificate. It is a Member’s responsibility to consult with the PCP in all matters regarding the Member’s medical care. If the Member’s PCP performs, suggests, or recommends a Member for a course of treatment that includes services that are not Covered Benefits, the entire cost of any such non-covered services will be the Member’s responsibility, subject to written notification to the Member by the PCP and written acceptance by the Member. C. Availability of Providers. HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, the Member will be notified and given an opportunity to make another PCP selection. The Member must then cooperate with HMO to select another PCP. D. Changing a PCP. A Member may change the PCP at any time by calling the Member Services 800 telephone number listed on the Member’s identification card or by written or electronic submission of the HMO’s change form. A Member may contact HMO to request a change form or for assistance in completing that form. The change will become effective upon HMO’s receipt and approval of the request. E. Ongoing Reviews. HMO conducts ongoing reviews of those services and supplies which are recommended or provided by Health Professionals to determine whether such services and supplies are Covered Benefits under this Certificate. If HMO determines that the recommended services and supplies are not Covered Benefits, the Member will be notified. If a Member wishes to appeal such determination, the Member may then contact HMO to seek a review of the determination. F. Authorization. Certain services and supplies under this Certificate may require authorization by HMO to determine if they are Covered Benefits under this Certificate. Those services and supplies requiring HMO authorization are indicated in this Certificate. HMO/NV INDDISCBASIC 3/99 1 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN ELIGIBILITY AND ENROLLMENT A. Eligibility. 1. To be eligible to enroll as a Subscriber, an individual must: a. live or work in the Service Area; and E L P M A S b. be a former Subscriber in an HMO plan, whose coverage terminated under a Group Agreement and to whom the conversion privilege is available there under. 2. To be eligible to enroll as a Covered Dependent the dependent must be: a. the legal spouse of a Subscriber; or b. a dependent unmarried child (including natural, foster, step, legally adopted children, proposed adoptive children, and a child under court order) who meets the eligibility requirements described on the Schedule of Benefits. 3. A Member who resides outside the Service Area is required to choose a PCP and return to the Service Area for Covered Benefits. Members shall be covered for Emergency Services and Urgent Care services only when obtained outside the Service Area. B. Enrollment. Unless otherwise noted, an eligible individual and any eligible dependents may enroll in HMO regardless of health status, age, or requirements for health services within 45 days from the date of termination of eligibility as a Subscriber under a Group Agreement. 1. Newly Eligible Individuals and Eligible Dependents. An eligible individual and any eligible dependents may enroll within 31 days of the termination of eligibility date. 2. Enrollment of Newly Eligible Dependents. a. Newborn Children. A newborn child is covered for 31 days from the date of birth. To continue coverage beyond this initial period, the child must be enrolled in HMO within the initial 31 day period. If coverage does not require the payment of an additional Premium for a Covered Dependent, the Subscriber must still enroll the child within 31 days after the date of birth. The coverage for newly born, adopted children, and children placed for adoption consists of coverage of injury and sickness, including the necessary care and treatment of congenital defects and birth abnormalities, and within the limits of this Certificate. Coverage includes necessary transportation costs from place of birth to the nearest specialized Participating treatment center. b. Adopted Children. A legally adopted child or a child for whom a Subscriber is a court appointed legal guardian, and who meets the definition of a Covered Dependent, will be treated as a dependent from the date of adoption or upon the date the child was placed for adoption with the Subscriber. “Placed for adoption” means the assumption and retention of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The placement must take effect on or after the date a Subscriber’s coverage becomes effective, and the Subscriber must make a written request for coverage within 31 days of the date the child is adopted or placed with the Subscriber for adoption. HMO/NV INDDISCBASIC 3/99 2 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN The initial coverage will not be affected by any provision in this Certificate which: i. requires evidence of good health acceptable to HMO for coverage to become effective; ii. delays coverage due to a confinement; or iii. limits coverage as to a preexisting condition. 3. Special Rules Which Apply to Children. E L P M A S a. Qualified Medical Support Order. Coverage is available for a dependent child not residing with a Subscriber and who resides outside the Service Area, if there is a qualified medical child support order requiring the Subscriber to provide dependent health coverage for a non-resident child, and is issued on or after the date the Subscriber’s coverage becomes effective. The child must meet the definition of a Covered Dependent, and the Subscriber must make a written request for coverage within 31 days of the court order. The initial coverage will not be affected by any provision in this Certificate which: i. requires evidence of good health acceptable to HMO for coverage to become effective; ii. delays coverage due to a confinement; or iii. limits coverage as to a preexisting condition. b. Handicapped Children. Coverage is available for a child who is chiefly dependent upon the Subscriber for support and maintenance, and who is 19 years of age or older but incapable of self-support due to mental or physical incapacity. The incapacity must have commenced prior to the age the dependent lost eligibility. In order to continue coverage for a handicapped child, the Subscriber must provide evidence of the child’s incapacity and dependency to HMO within 31 days of the date the child’s coverage would otherwise terminate. Proof of continued incapacity, including a medical examination, must be submitted to HMO as requested, but not more frequently than annually beginning after the two year period following the child’s attainment of the age specified on the Schedule of Benefits. This eligibility provision will no longer apply on the date the dependent’s incapacity ends. 4. Notification of Change in Status. It shall be a Member’s responsibility to notify HMO of any changes which affect the Member’s coverage under this Certificate. Such status changes include, but are not limited to, change of address, change of Covered Dependent status, and enrollment in Medicare or any other group health plan of any Member. Additionally, if requested, a Subscriber must provide to HMO, within 31 days of the date of the request, evidence satisfactory to HMO that a dependent meets the eligibility requirements described in this Certificate. An eligible individual and any eligible dependents may be enrolled if the eligible individual’s spouse was covered under another health benefit plan and lost coverage because of termination of coverage, for reasons other than gross misconduct, within 31 days of the loss of coverage even though it is not during the Open Enrollment Period. HMO’s completed change form must be submitted to the Contract Holder within 31 days of the event causing the change in status. C. Effective Date of Coverage. Coverage shall take effect at 12:01 a.m. on the Member’s effective date. Coverage shall continue in effect from month to month subject to payment of Premiums made by the Contract Holder and subject to the Termination section of this Certificate. HMO/NV INDDISCBASIC 3/99 3 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN COVERED BENEFITS A Member shall be entitled to the Covered Benefits as specified below, in accordance with the terms and conditions of this Certificate. Unless specifically stated otherwise, in order for benefits to be covered, they must be Medically Necessary. For the purpose of coverage, HMO may determine whether any benefit provided under the Certificate is Medically Necessary, and HMO has the option to only authorize coverage for a Covered Benefit performed by a particular Provider. Preventive care, as described below, will be considered Medically Necessary. E L P M A S To be Medically Necessary, the service or supply must: I I I be care or appropriate necessary and required services, according to generally accepted principles of medical practice for the diagnosis or treatment of an existing illness or injury, except for covered periodic health evaluations and preventive and well baby care, as determined by HMO; include only those services and supplies that cannot be safely and satisfactorily provided at home, in a Physician’s office, on an outpatient basis, or in any facility other than a Hospital, when used in relation to inpatient Hospital services; and as to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any equally effective service or supply in meeting the above tests. In determining if a service or supply is Medically Necessary, HMO’s Patient Management Medical Director or its Physician designee will consider: I information provided on the Member’s health status; I reports in peer reviewed medical literature; I I reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment; I the opinion of Health Professionals in the generally recognized health specialty involved; I the opinion of the attending Physicians, which have credence but do not overrule contrary opinions; and I any other relevant information brought to HMO’s attention. All Covered Benefits will be covered in accordance with the guidelines determined by HMO. If a Member has questions regarding coverage under this Certificate, the Member may call the Member Services 800 telephone number listed on the Member’s identification card. THE MEMBER IS RESPONSIBLE FOR PAYMENT OF THE APPLICABLE COPAYMENTS LISTED ON THE SCHEDULE OF BENEFITS. EXCEPT FOR DIRECT ACCESS SPECIALIST BENEFITS OR IN A MEDICAL EMERGENCY OR URGENT CARE SITUATION AS DESCRIBED IN THIS CERTIFICATE, THE FOLLOWING BENEFITS MUST BE ACCESSED THROUGH THE PCP’S OFFICE THAT IS SHOWN ON THE MEMBER’S IDENTIFICATION CARD, OR ELSEWHERE UPON PRIOR REFERRAL ISSUED BY THE MEMBER’S PCP. A. Primary Care Physician Benefits. 1. Office visits during office hours. 2. Home visits. 3. After-hours PCP services. PCPs are required to provide or arrange for on-call coverage 24 hours a day, 7 days a week. If a Member becomes sick or is injured after the PCP’s regular office hours, the Member should: HMO/NV INDDISCBASIC 3/99 4 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN a. call the PCP’s office; and b. identify himself or herself as a Member; and c. follow the PCP’s or covering Physician’s instructions. If the Member’s injury or illness is a Medical Emergency, the Member should follow the procedures outlined under the Emergency Care/Urgent Care Benefits section of this Certificate. E L P M A S 4. Hospital visits. 5. Periodic health evaluations to include: a. well child care from birth including immunizations and booster doses of all immunizing agents used in child immunizations which conform to the standards of the Advisory Committee on Immunization Practices of the Centers for Disease Control, U.S. Department of Health and Human Services. b. routine physical examinations. c. routine gynecological examinations, including Pap smears, for routine care, administered by the PCP. Or the Member may also go directly to a Participating gynecologist without a Referral for routine GYN examinations and Pap smears. See the Direct Access Specialist Benefits section of this Certificate for a description of these benefits. d. routine hearing screenings. e. immunizations (but not if solely for the purpose of travel or employment). f. routine vision screenings. 6. Injections, including allergy desensitization injections. 7. Casts and dressings. 8. Health Education Counseling and Information. B. Diagnostic Services. Services include, but are not limited to, the following: 1. diagnostic, laboratory, and x-ray services. 2. mammograms, by a Participating Provider. The Member is required to obtain a Referral from her PCP or gynecologist, or obtain prior authorization from HMO to a Participating Provider, prior to receiving this benefit. Screening mammogram benefits for female Members are provided as follows: I I I One baseline mammogram between the ages of 35 and 40. age 40 and older, one routine mammography at age forty and every twelve month period thereafter from the initial exam; or when Medically Necessary. 3. annual cytologic screening test for women 18 years of age or older. HMO/NV INDDISCBASIC 3/99 5 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN C. Specialist Physician Benefits. Covered Benefits include outpatient and inpatient services. D. Direct Access Specialist Benefits. The following services are covered without a Referral when rendered by a Participating Provider. I I Routine Gynecological Examination(s). Routine gynecological visit(s) and Pap smear(s). The number of visits, if any, is listed on the Schedule of Benefits. E L P M A S Open Access to Gynecologists. Benefits are provided to female Members for services performed by a Participating gynecologist for diagnosis and treatment of gynecological problems. See the Infertility Services section of this Certificate for a description of Infertility benefits. E. Maternity Care and Related Newborn Care. Complications of Pregnancy - Member is covered for complications of pregnancy, including any condition which requires Hospital confinement for Medically Necessary treatment and: a) If the pregnancy is not terminated, if caused by an injury or sickness not directly related to the pregnancy or by acute nephritis, nephrosis, cardiac decompensation, missed abortion or similarly medically diagnosed condition; or, b) If the pregnancy is terminated, results in nonelective cesarean section, ectopic pregnancy or spontaneous termination. F. Inpatient Hospital & Skilled Nursing Facility Benefits. A Member is covered for services only at Participating Hospitals and Participating Skilled Nursing Facilities. All services are subject to preauthorization by HMO. In the event that the Member elects to remain in the Hospital or Skilled Nursing Facility after the date that the Participating Provider and/or the HMO Medical Director has determined and advised the Member that the Member no longer meets the criteria for continued inpatient confinement, the Member shall be fully responsible for direct payment to the Hospital or Skilled Nursing Facility for such additional Hospital, Skilled Nursing Facility, Physician and other Provider services, and HMO shall not be financially responsible for such additional services. G. Transplants. Transplants which are non-experimental or non-investigational are a Covered Benefit. Covered transplants must be ordered by the Member’s PCP and Participating Specialist Physician and approved by HMO’s Medical Director in advance of the surgery. The transplant must be performed at Hospitals specifically approved and designated by HMO to perform these procedures. A transplant is non-experimental and noninvestigational hereunder when HMO has determined, in its sole discretion, that the Medical Community has generally accepted the procedure as appropriate treatment for the specific condition of the Member. Coverage for a transplant where a Member is the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program. H. Outpatient Surgery Benefits. Coverage is provided for outpatient surgical services and supplies in connection with a covered surgical procedure when furnished by a Participating outpatient surgery center. All services and supplies are subject to preauthorization by HMO. Reconstructive surgery following a mastectomy. The Member is responsible for a copayment in the amount shown on the Schedule of Benefits, if any. HMO/NV INDDISCBASIC 3/99 6 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN I. Emergency Care/Urgent Care Benefits. 1. A Member is covered for Emergency Services, provided the service is a Covered Benefit, and HMO’s review determines that a Medical Emergency existed at the time medical attention was sought by the Member. The Copayment for an emergency room visit as described on the Schedule of Benefits will not apply either in the event that the Member was referred for such visit by the Member’s PCP for services that should have been rendered in the PCP’s office or if the Member is admitted into the Hospital. E L P M A S The Member will be reimbursed for the cost for Emergency Services rendered by a nonparticipating Provider located either within or outside the HMO Service Area, for those expenses, less Copayments, which are incurred up to the time the Member is determined by HMO and the attending Physician to be medically able to travel or to be transported to a Participating Provider. In the event that transportation is Medically Necessary, the Member will be reimbursed for the cost as determined by HMO, minus any applicable Copayments. Reimbursement may be subject to payment by the Member of all Copayments which would have been required had similar benefits been provided during office hours and upon prior Referral to a Participating Provider. Medical transportation is covered during a Medical Emergency. 2. The Member will be covered for Urgent Care services obtained from a licensed Physician or facility outside of the Service Area if: a. the service is a Covered Benefit; b. the service is Medically Necessary and immediately required because of unforeseen illness, injury, or condition; and c. it was not reasonable, given the circumstances, for the Member to return to the HMO Service Area for treatment. 3. A Member is covered for any follow-up care. Follow-up care is any care directly related to the need for emergency care which is provided to a Member after the Medical Emergency care or Urgent Care situation has terminated. All followup and continuing care must be provided or arranged by a Member’s PCP. The Member must follow this procedure, or the Member will be responsible for payment for all services received. J. Rehabilitation Benefits. 1. Inpatient and Outpatient Rehabilitation Benefits. The following benefits are covered by Participating Providers upon Referral issued by the Member’s PCP and approved by HMO in advance of treatment. a. Cardiac rehabilitation benefits are available as part of a Member’s inpatient Hospital stay. A limited course of outpatient cardiac rehabilitation is covered when Medically Necessary following angioplasty, cardiovascular surgery, congestive heart failure or myocardial infarction. b. Pulmonary rehabilitation benefits are available as part of a Member’s inpatient Hospital stay. A limited course of outpatient pulmonary rehabilitation is covered when Medically Necessary for the treatment of reversible pulmonary disease states. HMO/NV INDDISCBASIC 3/99 7 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN 2. Outpatient Rehabilitation Benefits. The following benefits are covered by Participating Providers upon Referral issued by the Member’s PCP and approved by HMO in advance of treatment. Coverage is subject to the limits, if any, shown on the Schedule of Benefits. a. Cognitive therapy associated with physical rehabilitation is covered for non-chronic conditions and acute illnesses and injuries as part of a treatment plan coordinated with HMO. E L P M A S b. Physical therapy is covered for non-chronic conditions and acute illnesses and injuries. c. Occupational therapy (except for vocational rehabilitation or employment counseling) is covered for non-chronic conditions and acute illnesses. d. Speech therapy is covered for non-chronic conditions and acute illnesses and injuries. Services rendered for the treatment of delays in speech development, unless resulting from disease, injury, or congenital defects, are not covered. K. Home Health Benefits. The following services are covered when rendered by a Participating home health care agency. Preauthorization must be obtained from the Member’s attending Participating Physician. HMO shall not be required to provide home health benefits when HMO determines the treatment setting is not appropriate, or when there is a more cost effective setting in which to provide appropriate care. Coverage is subject to the maximum number of visits, if any, shown on the Schedule of Benefits. 1. Skilled nursing services for a Homebound Member. Treatment must be provided by or supervised by a registered nurse. 2. Services of a home health aide. These services are covered only when the purpose of the treatment is Skilled Care. 3. Medical social services. Treatment must be provided by or supervised by a qualified medical Physician or social worker, along with other Home Health Services. The PCP must certify that such services are necessary for the treatment of the Member’s medical condition. 4. Short-term physical, speech, or occupational therapy is covered. Services are subject to the limitations listed in the Rehabilitation Benefits section of this Certificate. L. Hospice Benefits. Hospice Care services for a terminally ill Member are covered when preauthorized by HMO. Services may include home and Hospital visits by nurses and social workers; pain management and symptom control; instruction and supervision of a family Member; inpatient care; counseling and emotional support; and other home health benefits listed above. Coverage is not provided for bereavement counseling, funeral arrangements, pastoral counseling, financial or legal counseling. Homemaker or caretaker services, and any service not solely related to the care of the Member, including but not limited to, sitter or companion services for the Member or other Members of the family, transportation, house cleaning, and maintenance of the house are not covered. Coverage is not provided for Respite Care. M. Prosthetic Appliances. The Member’s initial provision of a prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease or injury or congenital defects is covered, when such device is prescribed by a Participating Provider and authorized in advance by HMO, including at least 2 breast prostheses subsequent to a mastectomy. Coverage includes repair and replacement when due to congenital growth. Instruction and appropriate services required for the Member to properly use the item (such as attachment or insertion) are covered. HMO/NV INDDISCBASIC 3/99 8 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN N. Injectable Medications. Injectable medications, including those medications intended to be self administered, are a Covered Benefit when an oral alternative drug is not available, unless specifically excluded as described in the Exclusions and Limitations section of this Certificate. Medications must be prescribed by a Provider licensed to prescribe federal legend prescription drugs or medicines, and approved in advance of treatment by HMO. If the drug therapy treatment is approved for self-administration, the Member is required to obtain covered medications at an HMO Participating pharmacy designated to fill injectable prescriptions. E L P M A S Injectable drugs or medication used for the treatment of cancer or HIV are covered when the off-label use of the drug has not been approved by the FDA for that indication, provided that such drug is recognized for treatment of such indication in one of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) and the safety and effectiveness of use for this indication has been adequately demonstrated by at least one study published in a nationally recognized peer reviewed journal. O. Temporomandibular Joint Syndrome Services. Oral Surgery, limited to bony impactions of teeth, bone fractures, removal of tumors and orthodontogenic cysts or other pre approved surgical procedures. Coverage for the treatment for temporomandibular joint dysfunction shall include preauthorized Medically Necessary procedures. Medically Necessary excludes dental procedures including, but not limited to, the extraction of teeth and the application of orthodontic devices and splints. P. Enteral Formulas 1. Enteral formulas for use at home that are prescribed or ordered by a Participating Provider as medically necessary are covered for the treatment of inherited metabolic diseases characterized by deficient metabolism, or malabsorption originating from congenital defects or defects arising shortly after birth, of amino acid, organic acid, carbohydrate or fat. 2. Coverage will be provided for at least $2,500 per year for Special Food Products which are prescribed or ordered by a Participating Provider as medically necessary for the treatment of a Member described in section 1 above. “Inherited Metabolic Disease” means a disease caused by an inherited abnormality of the body chemistry of a person. “Special Food Product” means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be consumed under the direction of a Participating Provider for the dietary treatment of an inherited metabolic disease. The term does not include a food that is naturally low in protein. Q. Diabetes. The management and treatment of Diabetes (type I, type II and gestational) is covered, including coverage for the selfmanagement of Diabetes. Coverage for the management and treatment of Diabetes includes coverage for medication, equipment, supplies and appliances that are Medically Necessary for the treatment of Diabetes. Coverage, without limitation, for the self-management of Diabetes, includes : 1. Training and education provided to the Member after the original diagnosis, including counseling in nutrition and the proper use of equipment and supplies for the treatment of Diabetes; HMO/NV INDDISCBASIC 3/99 9 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN 2. Training and education as a result of a subsequent diagnosis that indicates a significant change in the symptoms or condition of the Member and which requires modification of the program of self-management; and 3. Training and education due to the development of new techniques and treatment for Diabetes. R. Durable Medical Equipment Benefits. Durable Medical Equipment will be provided when preauthorized by HMO. The wide variety of Durable Medical Equipment and continuing development of patient care equipment makes it impractical to provide a complete listing, therefore, the HMO Medical Director has the authority to approve requests on a case-by-case basis. Covered Durable Medical Equipment includes those items covered by Medicare unless excluded in the Exclusions and Limitations section of this Certificate. HMO reserves the right to provide the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of HMO. E L P M A S Instruction and appropriate services required for the Member to properly use the item, such as attachment or insertion, is also covered upon preauthorization by HMO. Replacement, repairs and maintenance are covered only if the HMO is shown that: 1. it is needed due to a change in the Member’s physical condition; or 2. it is likely to cost less to buy a replacement than to repair the existing equipment or to rent like equipment. All maintenance and repairs that result from a misuse or abuse are a Member’s responsibility. A Copayment, a maximum annual out-of-pocket payment, and a maximum annual benefit may apply to this service. Refer to the Schedule of Benefits attached to this Certificate. EXCLUSIONS AND LIMITATIONS A. Exclusions. The following services are not covered. I I I I I I Services for which coverage is not specifically provided, complications resulting from non-Covered Services, or services which are not Medically Necessary, whether or not recommended or provided by a Provider. Personal comfort, hygiene, or convenience items such as a Hospital television, telephone, or private room when not Medically Necessary. Housekeeping or meal services as part of Home Health Care. Modifications to a place of residence, including equipment to accommodate physical handicaps or disabilities. For a private room in excess of the average semi-private room and board rate. Dental or orthodontic splints or dental prostheses, or any treatment on or to teeth, gums, or jaws and other services customarily provided by a dentist. Charges for dental services in connection with temporomandibular joint dysfunction are also not covered unless they are determined to be Medically Necessary. Such dental-related services are subject to the limitation shown in the Schedule of Benefits. Except for reconstructive surgery following a mastectomy, cosmetic procedures to improve appearance without restoring a physical bodily function. Third-party physical exams for employment, licensing, insurance, school, camp, sports, or adoption purposes. Immunizations related to foreign travel. Expenses for medical reports, including presentation and preparation. Exams or treatment ordered by a court, or in connection with legal proceedings if not Medically Necessary or a covered service. HMO/NV INDDISCBASIC 3/99 10 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN I I I I I I I I I For fertility or infertility studies, diagnostic testing, advice, consultation, examination, medication, or for any treatment related to or connected in any way with the restoration or enhancement of fertility or conception by artificial means including Embryo transplants, in vitro fertilization, GIFT and ZIFT procedures and low tubal transfers. For the treatment of sexual dysfunction or inadequacies, including, but not limited to, impotence and implantation of a penile prosthesis. Reversal of surgically performed sterilization or subsequent resterilization. Charges for genetic testing, counseling, treatment or therapy. E L P M A S Elective abortions. Surgical or invasive treatment (including gastric balloon) or reversal for reduction of weight regardless of associated medical or psychological conditions, unless determined to be Medically Necessary. Any weight loss programs, whether or not recommended, provided or prescribed by a Physician or other medical practitioner. Treatment of chronic marital or family problems; occupational, religious, or other social maladjustments; chronic behavior disorders; codependency; impulse control disorders, organic disorders, learning disabilities or mental retardation. Institutional care which is determined to be for the primary purpose of controlling Member’s environment and Custodial Care, domiciliary care, convalescent care (other than skilled nursing care) or rest cures. Vision exams to determine refractive errors of vision and aye glasses or contact lenses. Coverage is provided for vision exams only when required to diagnose an illness or injury. Hearing exams to determine the need for or the appropriate type of hearing aid or similar. Coverage is provided for hearing exams only when required to diagnose an illness or injury. Ecological or environmental medicine. Use of chelation, orthomolecular substances; use of substances of animal, vegetable, chemical or mineral origin not specifically approved by the FDA as effective for treatment; electrodiagnosis; Hahnemannian dilution and succussion; magnetically energized geometric patterns; replacement of metal dental filling; laetrile; gerovital. I Services for chronic, intractable pain by a pain control center or under a pain control program. I Acupuncture or hypnosis. I Treatment of an illness or injury resulting from riots, war, insurrection; rebellion; or armed invasion or aggression. I I I I I I Treatment of an occupational injury or illness which is any injury or illness arising out of or in the course of employment for pay or profit. Travel and accommodations, whether or not recommended or prescribed by a Provider. Vitamins, herbal medicines, appetite suppressants, and other over-the-counter drugs. Drugs and medicines approved by the FDA for experimental or investigational use. Any services provided before the Effective Date of Coverage or after the termination of coverage. Care for conditions that federal, state or local law requires to be treated in a public facility for which a charge is not normally made. Any equipment or supplies that condition the air, arch supports, support stockings, special shoe accessories or corrective shoes unless they are an integral part of a lower-body brace, hearing pads, hot water bottles, wigs and their care and other primarily nonmedical equipment. HMO/NV INDDISCBASIC 3/99 11 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN I I I Special formulas, food supplements other than as specifically covered or special diets on an outpatient basis. (Except for the treatment of inherited metabolic disease) Services, supplies or accommodations provided without cost to the Member or which the Member is not legally required to pay. Milieu therapy, biofeedback, behavior modification, sensitivity training, hypnosis, hydotherapy, electrohypnosis, electrosleep therapy, electonarcosis, narcosynthesis, rolffing, residential treatment, vocational rehabilitation and wilderness programs. E L P M A S I Experimental or investigational treatment or devices. I Sports medicine treatment plans intended to primarily improve athletic ability. I I I I I I Radial keratotomy or any surgical procedure for the improvement of vision when vision can be made adequate through the use of glasses or contact lenses. Any services given by a Provider to himself or to members of his family. Ambulance services when a Member could be safely transported by other means. Air ambulance services when a member could be safely transported by ground ambulance or other means. Late discharge billing and charges resulting from a canceled appointment or procedure. Care or treatment of an illness or injury caused by or arising out of participation in a riot, war, insurrection, rebellion, armed invasion or aggression; or sustained by a Member while in the act of committing a felony. If you are eligible for Medicare, any services covered by Medicare under Parts A and B are excluded to the extent actually paid for by Medicare (applicable to individual coverage only). I Subluxation Benefits. I Mental Health Benefits. I Substance Abuse Benefits. I Maternity Benefits. B. Limitations. I I In the event there are two or more alternative Medical Services which in the sole judgment of HMO are equivalent in quality of care, HMO reserves the right to provide coverage only for the least costly Medical Service, as determined by HMO, provided that HMO approves coverage for the Medical Service or treatment in advance. Determinations regarding eligibility for benefits, coverage for services, benefit denials and all other terms of this Certificate are at the sole discretion of HMO, subject to the terms of this Certificate. DETERMINATIONS REGARDING DENIAL OF BENEFITS DUE TO INAPPROPRITE USE OF THE HMO NETWORK ARE AT THE SOLE DISCRETION OF THE HMO. HMO/NV INDDISCBASIC 3/99 12 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN TERMINATION OF COVERAGE A Member’s coverage under this Certificate will terminate upon the earliest of any of the conditions listed below, and termination will be effective on the date indicated on the Schedule of Benefits. A. Termination of Subscriber Coverage. A Subscriber’s coverage will terminate for any of the following reasons: E L P M A S 1. the Certificate terminates; 2. the Subscriber is no longer eligible as outlined in the Eligibility and Enrollment section of this Certificate; 3. the Subscriber terminates this Certificate on any Premium due date by giving 30 days’ prior written notice; 4. the Contract Holder terminates this Certificate as of its renewal date, by providing HMO written notice of non-renewal not less than 30 days prior to the renewal date; 5. the Contract Holder terminates this Certificate as of the date any Premium change would become effective, by providing HMO with written notice of termination not less than 30 days prior to such effective date; or 6. the Subscriber’s eligibility for Medicare. B. Termination of Dependent Coverage. A Covered Dependent’s coverage will terminate for any of the following reasons: 1. a Covered Dependent is no longer eligible, as outlined in the Eligibility and Enrollment section of this Certificate and on the Schedule of Benefits; 2. the Certificate terminates; 3. the Subscriber’s coverage terminates; or 4. The Dependent’s eligibility for Medicare. C. Termination For Cause. HMO may terminate coverage for cause: 1. upon 31 days advance written notice in the event that HMO does not receive payment from the Contract Holder for the entire Premium due under this Certificate within the grace period. Coverage will terminate as of the last day for which Premiums were received, subject to the grace period. The termination of this Certificate following the expiration of the grace period shall not relieve the Contract Holder of its obligation to pay the Premium for coverage provided during the grace period. 2. upon 31 days advance written notice, if the Member has failed to make any required Copayment or any other payment which the Member is obligated to pay. Upon the effective date of such termination, prepayments received by HMO on account of such terminated Member or Members for periods after the effective date of termination shall be refunded to Contract Holder. HMO/NV INDDISCBASIC 3/99 13 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN 3. upon 31 days advance written notice of discovering a material misrepresentation by the Member in applying for or obtaining coverage or benefits under this Certificate or discovering that the Member has committed fraud against HMO. This may include, but is not limited to, furnishing incorrect or misleading information to HMO, or allowing or assisting a person other than the Member named on the identification card to obtain HMO benefits. HMO may, at its discretion, rescind a Member’s coverage on and after the date that such misrepresentation or fraud occurred. It may also recover from the Member the reasonable and recognized charges for Covered Benefits, plus HMO’s cost of recovering those charges, including reasonable attorneys’ fees. In the absence of fraud or material misrepresentation, all statements made by any Member or any person applying for coverage under this Certificate will be deemed representations and not warranties. No statement made for the purpose of obtaining coverage will result in the termination of coverage or reduction of benefits unless the statement is contained in writing and signed by the Member, and a copy of same has been furnished to the Member prior to termination. E L P M A S No termination shall relieve the Contract Holder from any obligation incurred prior to the date of termination of this Certificate. HMO shall have no further liability or responsibility under this Certificate except for coverage for Covered Benefits provided prior to the date of termination of coverage. The fact that Members are not notified by the Contract Holder of the termination of their coverage due to the termination of the Certificate shall not deem the continuation of a Members’ coverage beyond the date coverage terminates. A Member may request that HMO conduct a grievance hearing, as described in the Grievance Procedure section of this Certificate, within 15 working days after receiving notice that HMO has or will terminate the Member’s coverage as described in the Termination For Cause subsection of this Certificate. HMO will continue the Member’s coverage in force until a final decision on the grievance is rendered, provided the Premium is paid throughout the period prior to the issuance of that final decision. HMO may rescind coverage, to the date coverage would have terminated had the Member not requested a grievance hearing, if the final decision is in favor of HMO. If coverage is rescinded, HMO will refund any Premiums paid for that period after the termination date, minus the cost of Covered Benefits provided to a Member during this period. Coverage will not be terminated on the basis of a Member’s health status or health care needs, nor if a Member has exercised the Member’s rights under the Certificate’s Grievance Procedure to register a complaint against HMO. The grievance process described in the preceding paragraph applies only to those terminations affected pursuant to the Termination for Cause subsection of this Certificate. CONTINUATION A. Extension of Benefits While Member is Receiving Inpatient Care. Any Member who is receiving inpatient care in a Hospital or Skilled Nursing Facility on the date coverage under this Certificate terminates is covered in accordance with the Certificate only for the specific medical condition causing that confinement or for complications arising from the condition causing that confinement, until the earlier of: 1. the date of discharge from such inpatient stay; or 2. determination by the HMO Medical Director in consultation with the attending Physician, that care in the Hospital or Skilled Nursing Facility is no longer Medically Necessary; or 3. the date the contractual benefit limit has been reached; or 4. the date the Member becomes covered for similar coverage from another health benefits plan; or 5. 12 months from the termination date of the Certificate. HMO/NV INDDISCBASIC 3/99 14 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN The extension of benefits shall not extend the time periods during which a Member may enroll for continuation or conversion coverage, expand the benefits for such coverage, nor waive the requirements concerning the payment of Premium for such coverage. B. Rights of Dependents to Conversion Coverage. 1. A dependent shall be entitled to convert to an individual conversion policy if: E L P M A S a. the dependent is not eligible to enroll in Medicare, or under any other state or federal law providing benefits similar to those provided by the conversion option; and b. the dependent ceases to meet the eligibility requirements set forth in the Eligibility and Enrollment section of this Certificate and the Dependent Eligibility section of the Schedule of Benefits because of age, or divorce of the Subscriber, except that the newborn of a dependent-Member (e.g., grandchild) who is not eligible for coverage is entitled to individual conversion coverage. 2. A dependent shall not be entitled to convert to an individual policy if the Subscriber of the dependent , or the dependent has failed to apply and remit Premium payment for this conversion option within the 45 day period following loss of coverage. 3. In the event of the death of the Subscriber, or the Subscriber’s termination by the HMO for cause pursuant to the Termination of Coverage section of this Certificate, the spouse and/or dependent(s) will automatically become the Subscriber of this Certificate and there will be no need for the surviving dependent(s) to apply for individual conversion coverage. 4. The dependent may convert to an individual policy if the dependent: a. applies to HMO within 45 days after the effective date of termination; b. makes the applicable Premium payment; and c. continues to make the applicable Premium payments. 5. HMO is not responsible for giving the Member notice of the conversion option. Forms for conversion, including the enrollment and change form and the health questionnaire, where applicable, are available from HMO. The first Premium payment must also be received within 45 days of the effective date of termination. Individual policy coverage will not be effective if the application and Premium payment are not received within 45 days of the effective date of termination. Benefits will be the same as the benefits listed in the Covered Benefits section of this Certificate. 6. The Effective Date of Coverage for conversion to an individual policy coverage shall be the date coverage is terminated under this Certificate if the enrollment and change form and Premium payment are received within 45 days of the effective date of termination. Coverage will continue in accordance with the terms of this Certificate. GRIEVANCE PROCEDURE The following procedures govern complaints, grievances, and grievance appeals made or submitted by Members. A. Definitions. 1. An “inquiry” is a Member’s request for administrative service, information, or to express an opinion, including but not limited to, claims regarding scope of coverage for health services, denials, cancellations, terminations or renewals, and the quality of services provided. HMO/NV INDDISCBASIC 3/99 15 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN 2. A “grievance” is a complaint that may or may not require specific corrective action, and is made in writing to HMO, or an inquiry which remains unresolved after a 60 day period after receipt of HMO. B. Grievance Review. 1. A written notice shall be sent by HMO to the Member: i. acknowledging each grievance; and E L P M A S ii. inviting the Member to provide any additional information to assist HMO in handling and deciding the grievance; and iii. informing the Member of the Member’s right to have an uninvolved HMO representative assist the Member in understanding the grievance process; and iv. informing the Member as to when a response should be forthcoming. 2. The Grievance Coordinator deciding the grievance shall be comprised of one or more employees of HMO. It shall not include any person whose decision is being appealed, any person who made the initial decision regarding the claim, or any person with previous involvement with the grievance. The Grievance Committee shall review and decide the grievance within 30 days of receipt unless additional information necessary to resolve the grievance is not received during such time, or by the mutual written agreement of HMO and the Member. 3. A written notice stating the result of the review by the Grievance Coordinator shall be forwarded by HMO to the Member within 10 working days of the date of the decision. Such notice shall include: a. a description of the Coordinator’s understanding of the Member’s grievance as presented to the Grievance Coordinator (i.e., dollar amount of the disputed issue, medical facts in dispute, etc.); and b. the Coordinator’s decision in clear terms, including the contract basis or medical rationale, as applicable, in sufficient detail for the Member to respond further to HMO’s position (i.e., the Member did not contact the PCP, the services were non-emergency services as identified in the medical report, the services were not covered by the Certificate, etc.); and c. citations to the evidence or documentation used as the basis for the decision (i.e., reference to the Certificate, medical records, etc.); and d. a statement indicating: i. that if the Member is not satisfied with the Grievance Coordinator’s decision, the Member has the right to appeal in writing to the Grievance Appeal Committee within 30 days of the date of the notice of the decision o the Grievance coordinator; and ii. a description of the process of how to appeal to the Grievance Appeal Committee; and C. Appeal Hearing. 1. Upon receipt of a written appeal by the Grievance Appeal Committee, HMO shall provide the Member filing the appeal with the procedures governing appeals before the Grievance Appeal Committee. The Member shall be notified of the Member’s right to have an uninvolved HMO representative available to assist the Member in understanding the appeal process. HMO/NV INDDISCBASIC 3/99 16 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN 2. The Grievance Appeal Committee shall be established by the Board of Directors of the HMO and shall be comprised of three members, one of whom shall be a non-employee Subscriber of the HMO. The Grievance Appeal Committee shall not include any person previously involved with the grievance. An HMO Medical Director may serve as a member of the Committee if the Medical Director was not previously involved with the grievance. 3. The Grievance Appeal Committee shall hold appeal hearings in HMO offices on a certain day each month to consider all appeals filed seven business days or more in advance of the hearing day. In the event a Member is unable to attend the hearing on the scheduled hearing day, the Member may request that their appeal be heard on the next scheduled hearing day. If no scheduled hearing day is suitable for the Member, the hearing will be scheduled for the following month. E L P M A S 4. The Member shall have the right to attend the appeal hearing, question the representative of HMO designated to appear at the hearing and any other witnesses, and present their case. The Member shall also have the right to be assisted or represented by a person of the Member’s choice, and submit written material in support of their grievance. The Member may bring a Physician or other expert(s) to testify on the Member’s behalf. HMO shall also have the right to present witnesses. Counsel for the Member may present the Member’s case and question witnesses; if the Member is so represented, HMO may be similarly represented by counsel. The Grievance Appeal Committee shall have the right to question the HMO representative, the Member and any other witnesses. 5. The appeal hearing shall be informal. The Grievance Appeal Committee shall not apply formal rules of evidence in reviewing documentation or accepting testimony at the hearing. The Chair of the Grievance Appeal Committee shall have the right to exclude redundant testimony or excessive argument by any party or witness. 6. A written record of the appeal hearing shall be made by stenographic transcription. All testimony shall be under oath. 7. Before the record is closed, the Chair of the Grievance Appeal Committee shall ask both the Member and the HMO representative (or their counsel) whether there is any additional evidence or argument which the party wishes to present to the Grievance Appeal Committee. Once all evidence and arguments have been received, the record of the appeal hearing shall be closed. The deliberations of the Grievance Appeal Committee shall be confidential and shall not be transcribed. 8. The Grievance Appeal Committee shall render a written decision within 30 working days of the conclusion of the appeal hearing. The decision shall contain: a. a statement of the Grievance Appeal Committee’s understanding of the nature of the grievance and the material facts related thereto; and b. the Grievance Appeal Committee’s decision and rationale; and c. a summary of the evidence, including necessary document supporting the decision; and d. a statement of the Member’s right to appeal to the Department of Insurance, with the phone number and complete address of the Department of Insurance. D. Emergency or Urgently Needed Care. 1. In the event a complaint requires specific action, and the Member or HMO believes serious medical consequences will arise in the near future, within up to 15 days from HMO’s denial to pay for the provision of allegedly Medically Necessary covered health services, the Member shall receive expedited review of their complaint. 2. In the event the issue is of an emergent nature, an HMO Medical Director shall review the matter as soon as possible or within 48 hours, and communicate a decision to the Member by telephone. HMO/NV INDDISCBASIC 3/99 17 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN 3. In the event the issue is of an urgent nature, an HMO Medical Director shall review the matter and make a determination within 96 hours of receipt. 4. An adverse decision by a Medical Director in either an emergent or urgent medical situation shall be immediately reviewed by an HMO Regional Medical Director or his designee. The decision of the Regional Medical Director shall be provided to the Member by telephone and confirmed in writing. E. Exhaustion of Process. E L P M A S The foregoing procedures and process are mandatory and must be exhausted prior to: 1. any investigation of a complaint by the Department of Insurance; or 2. the filing of a complaint with the Department of Insurance; or 3. the establishing of any litigation or arbitration, or any administrative proceeding regarding either any alleged breach of the Certificate by HMO, or any matter within the scope of the grievance resolution process of any complaint, grievance or grievance appeal. However, a Member can file a complaint with the Division of Insurance at any time. The complaint should be filed at the Nevada Division of Insurance, 1665 Hot Springs Road #152, Carson City, NV 89710, phone (702) 687-4270, at the Nevada Department of Insurance Toll-free consumer line 1-888-872-3234 or 1-800-992-0900 or in Las Vegas at the Nevada Division of Insurance, 2501 E. Sahara Ave. #302, Las Vegas, NV 89158, phone (702) 486-4009. F. Record Retention. HMO shall retain the records of all grievances for a period of at least 7 years. G. Fees and Costs. Nothing herein shall be construed to required HMO to pay counsel fees or any other fees or costs incurred by a Member in pursuing a grievance or appeal. COORDINATION OF BENEFITS Some Members have health coverage in addition to the coverage provided under this Certificate. When this is the case, the benefits paid by other plans will be taken into account. This may mean a reduction in benefits payable under this Certificate. When coverage under this Certificate and coverage under another plan applies, the order in which the various plans will pay benefits must be figured. This will be done as follows using the first rule that applies: A. A plan with no rules for coordination with other benefits will be deemed to pay its benefits before a plan which contains such rules. B. A plan which covers a person other than as a dependent will be deemed to pay its benefits before a plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary and as a result of the Social Security Act of 1965, as amended, Medicare is: 1. secondary to the plan covering the person as a dependent; and 2. primary to the plan covering the person as other than a dependent; HMO/NV INDDISCBASIC 3/99 18 DISCLOSURE BROCHURE AND SAMPLE CERTIFICATE OF COVERAGE FOR NEVADA INDIVIDUAL CONVERSION BASIC PLAN the benefits of a plan which covers the person as a dependent will be determined before the benefits of a plan which: 1. covers the person as other than a dependent; and 2. is secondary to Medicare. C. Except in the case of a dependent child whose parents are divorced or separated, the plan which covers the person as a dependent of a person whose birthday comes first in a calendar year will be primary to the plan which covers the person as a dependent of a person whose birthday comes later in that calendar year. If both parents have the same birthday, the benefits of a plan which covered one parent longer are determined before those of a plan which covered the other parent for a shorter period of time. E L P M A S If the other plan does not have the rule described in this provision (C) but instead has a rule based on the gender of the parent and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits. D. In the case of a dependent child whose parents are divorced or separated: 1. If there is a court decree which states that the parents shall share joint custody of a dependent child, without stating that one of the parents is responsible for the health care expenses of the child, the order of benefit determination rules specified in (C) above will apply. 2. If there is a court decree which makes one parent financially responsible for the medical, dental or other health care expenses of such child, the benefits of a plan which covers the child as a dependent of such parent will be determined before the benefits of any other plan which covers the child as a dependent child. 3. If there is not such a court decree: If