GROUP ADMINISTRATION DOCUMENT
HEALTH CARE BENEFITS
WHEREAS, the “Group” or “Employer” has purchased health care insurance from Blue Cross and Blue Shield of Oklahoma (herein cal1ed BCBSOK or Plan) Tulsa, Oklahoma, and has executed a Benefit Program ApplicationorGroup Application; and
WHEREAS, the Benefit Program ApplicationorGroup Application establishes the Group Contract Date and the Account Number(s) of the Group under the Group Contract; and
WHEREAS, BCBSOK hereby accepts such Benefit Program ApplicationorGroup Application, subject to the financial and administrative relationships and responsibilities of both parties for the purpose of providing health care benefits on behalf of Eligible Persons;
NOW THEREFORE, the Group Contract is issued in consideration of the Benefit Program ApplicationorGroup Application and of the timely payment of premiums as required herein. The Group Contract shall become effective on the Group Contract Date specified on the Benefit Program ApplicationorGroup Application and will be continued in effect by the payment of premiums at the rates determined by the Plan in accordance with the provisions in Premiums and Group Contract Changes until terminated as provided in Termination of the Group Contract.
In Witness Whereof, the Plan has caused the Group Contract to be executed at its Administrative Office inTulsa,Oklahoma.
Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company
President of Blue Cross and Blue Shield of Oklahoma
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
TABLE OF CONTENTS
INTRODUCTION…………………………………………………………………………………..…… 3
I. DEFINITIONS APPLICABLE TO THIS GROUP ADMINISTRATION DOCUMENT…..... 3
II. RECORDS OF SUBSCRIBER ELIGIBILITY AND CHANGES IN
SUBSCRIBER ELIGIBILITY…………………………………………………………………… 5
III. PREMIUMS AND GROUP CONTRACT CHANGES……………………………….………… 5
IV. MINIMUM GROUP PARTICIPATION REQUIREMENTS….……………………………….6
V. TERMINATION OF THE GROUP CONTRACT…………………………..………………….. 7
VI.TERMINATION OF A SUBSCRIBER'S COVERAGE UNDER THE GROUP CONTRACT……………………………………………………………….……………..……….. 7
VII. NOTICE AND PROPERLY FILED CLAIMS…..………………………………..…………….. 8
VIII. RELEASE OF INFORMATION AND MEDICAL RECORDS…………..…..…..……..…….. 8
IX. PAYMENT OF BENEFITS………………………………………………………..……………... 9
X. BENEFIT DETERMINATION FOR PROPERLY FILED CLAIMS...……….…….….……..9
XI. PLAN'S RIGHT OF RECOUPMENT…………………...……….………….…….…….………9
XII. LIMITATIONS ON PLAN'S RIGHT OF RECOUPMENT/RECOVERY…………….……. 10
XIII. BENEFITS AFTER TERMINATION OF COVERAGE..…….…..…………………….……. 10
XIV. GENERAL PROVISIONS……………………………………….…………………….………... 11
XV. BLUECARD…………………………………………………………………………….……….. 17
XVI. NOTICE OF ANNUAL MEETING……………………………………….…………………….18
INTRODUCTION
The Group Contract between the Employer and BCBSOK is comprised of and is written in parts:
1.This Group Administration Document;
- The Benefit Program ApplicationorGroup Application;
- The Certificate of Benefits attached hereto; and
4.Any other applications, riders, enclosures, addenda, exhibits, and endorsements to any of them.
ThisGroup Administration Document contains those aspects of the Group Contract more specifically applicable to the Employer. The Certificate of Benefits contains information more specifically applicable to Members. In the event of any conflict between any components of the health care benefit plan, thisGroup Administration Document prevails.
I.DEFINITIONS APPLICABLE TO THIS GROUP ADMINISTRATION DOCUMENT
Additional definitions applicable to the Group Contract are contained in the Certificate of Benefits and the Group ApplicationorBenefit Program Application.
Allowable Charge – the charge that the Plan will use as the basis for Benefit determination for Covered Services Incurred by a Subscriber under the Group Contract. The criteria the Plan will use to establish the Allowable Charge is set forth in the Certificate of Benefits.
Benefit Period– the specified period of time during which charges for Covered Services must be Incurred in order to be eligible for payment by the Plan. A charge is Incurred on the date the service or supply was provided to a Subscriber.
Benefits– the payment, reimbursement and/or indemnification of any kind which a Subscriber will receive from and through the Plan under the Group Contract.
Certificateof Benefits– the document issued by the Plan to the Group, via an electronic file or access to an electronic file or otherwise, as applicable and as specified on the Group ApplicationorBenefit Program Application, for delivery to each Subscriber. The Certificate of Benefits describes the health care benefit plan purchased by the Group and being administered by the Plan pursuant to the Group Contract.
Certificate of Coverage – a document providing information which is intended to enable an individual to establish his/her prior Creditable Coverage for the purposes of reducing any Preexisting Condition Exclusion imposed on the individual by any subsequent Group Health Plan coverage.
Coinsurance–the percentage of Allowable Charges for Covered Services for which the Subscriber is responsible.
Covered Service–a service or supply specified in the Group Contract for which Benefits will be provided when rendered by a Provider.
Creditable Coverage– coverage of an individual from a wide range of specified sources, including Group Health Plans, health insurance coverage, Medicare, and Medicaid.
Deductible– a specified amount of Covered Services that a Subscriber must incur before the Plan will start to pay its share of the remaining Covered Services.
Dependent– a Subscriber other than the Member as specified in the Eligibility section of the Certificate of Benefits.
Effective Date– according to the Eligibility section of the Certificate of Benefits, the date on which coverage for a Subscriber begins.
Eligible Person– a person entitled to apply to be a Member as specifiedon the Group ApplicationorBenefit Program Application.
Group– a corporation, proprietorship, partnership, or other recognized legal entity, which, as an agent for its employees, has agreed to the establishment of a premium collection or payment system for the purpose of affording its employees the opportunity of acquiring Plan coverage for health care expenses.
Group ApplicationorBenefit Program Application–means the document through which the Group has applied for health care insurance from the Plan and by which renewals and/or other Group Contract changes may be documented.
Group Contract–this Group Administration Document, the Group ApplicationorBenefit Program Application, the Certificate of Benefits and Amendments or Endorsements, if any, between the Plan and the Group, referred to as the Master Contract or Group Contract.
Group Contract Date– the date, specified on theGroup ApplicationorBenefit Program Application, on which coverage under the Group Contract commences for the Group.
Group ContractDate Anniversary– the date the Group Contract will renew and each twelve (12)-consecutive-month renewal date thereafter.
Identification Card– the card issued to the Member by the Plan, bearing the Member's name, identification number, and Group number.
Inpatient – a Subscriber who is a registered bed patient in a Hospital or other Provider.
Medically Necessary (or Medical Necessity) – health care services that aHospital, Physician, or other Provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:
a.in accordance with generally accepted standards of medical practice;
b.clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for patient's illness, injury or disease; and
c.not primarily for the convenience of the patient, Physician, or other health care Provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.
Medicare– the programs of health care for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended.
Member – an Eligible Person who has enrolled for coverage.
Out-Of-Network Provider – a Provider that has not entered into an agreement with the Plan to be a part of the Participating Provider Network as set forth in the Certificate of Benefits.
Participating Provider –a Provider that has entered into an agreement with the Plan to be a part of the Participating Provider Network as set forth in the Certificate of Benefits.
Physician – a person who is a professional practitioner of a Healing Art defined and recognized by law, and who holds a Physician license duly issued by the state or territory of the United States in which the person is authorized to practice medicine or Surgery or other procedures and provide services within the scope of such license.
Plan – Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company.
Precertification – certification from the Plan before the services are rendered that, based upon the information presented by the Subscriber or his/her Provider at the time Precertification is requested, the proposed treatment meets the Plan's guidelines for Medical Necessity.
Precertification does not guarantee that the care and services a Subscriber receives are eligible for Benefits under the Contract. At the time the Subscriber's claims are submitted, they will be reviewed in accordance with the terms of the Contract.
Properly Filed Claim– a formal statement or claim regarding a loss which provides sufficient, substantiating information to allow the Plan to determine its liability for Covered Services. This includes: a completed claim form; the Provider's itemized statement of services rendered and related charges; and medical records, when requested by the Plan.
Provider– a Hospital, Physician, or other practitioner or Provider of medical services or supplies licensed to render Covered Services and performing within the scope of such license.
Service Mark – the names BLUE CROSS and/or BLUE SHIELD and the associated logos, along with all related or derivative marks including, but not limited to, any Blue Cross or Blue Shield formulas or designs.
Subscriber – the Member and each of his or her Dependents (if any) enrolled under the Group Contract.
Surcharges – the state or federal taxes, surcharges, or other fees paid by the Plan which are imposed upon or resulting from the Group Contract.
II.RECORDS OF SUBSCRIBER ELIGIBILITY AND CHANGES IN SUBSCRIBER ELIGIBILITY
A.The Group must furnish the Plan with any data required by the Plan for coverage of Subscribers under the Group Contract. In addition, the Group must provide prompt notification to the Plan of the effective date of any changes in a Subscriber's coverage status under the Group Contract.
B.All such notifications by the Group to the Plan (including, but not limited to, forms and tapes) must be furnished in a format approved by the Plan and must include all information reasonably required by the Plan to effect changes.Minor clerical errors in keeping or reporting data relative to coverage under the Group Contract will not invalidate coverage which would otherwise be validly in force or continue coverage which would otherwise validly terminate. Examples of such minor clerical errors include, but are not limited to, errors appearing in an individual’s name, address or birth date as well as typographical errors. The term “minor clerical errors” as used herein does not include Group errors which materially affect an individual’s coverage under the Group Contract. It is further understood and agreed that the Group is liable for any substantive error made by the Group in keeping or reporting data which may materially affect an individual’s coverage under the Group Contract and for any benefits paid for a terminated Subscriber if the Group had not timely notified the Plan of such Subscriber’s termination.
In the event of errors or delays in recording or reporting data by the Group, retroactive changes will not be made effective prior to the current month and two (2) previous months.
C.During the term of the Group Contract and within one-hundred eighty (180) days after the termination of the Group Contract, the Plan may, upon at least thirty (30) days prior written notice to the Group, conduct reasonable audits of the Group’s membership records with respect to eligibility.
D.The Group hereby agrees to indemnify and hold harmless the Plan and its employees and agents for any loss, damage, expense (including, but not limited to, reasonable attorney’s fees and costs) or liability that may arise from or in connection with untimely and/or inaccurate data provided by the Group to the Plan or data furnished by the Group to the Plan in a format not approved by the Plan.
III.PREMIUMS AND GROUP CONTRACT CHANGES
A.The amount of premiums shall be the amount determined by the Plan for the Benefits of the Group Contract, as filed with the Insurance Commissioner of the State of Oklahoma.
B.The Plan may establish new premiums for any of the individual or aggregate benefits of the Group Contract on any of the following dates or occurrences, upon which further premiums shall be paid.
1.Any Group Contract Date Anniversary, provided that the Plan notifies the Group of such new premium within the timeframe specified on the Benefit Program ApplicationorGroup Application;
2.Any premium due date, provided the Plan notifies the Group of such new premium within the timeframe specified on the Benefit Program ApplicationorGroup Application;
3.Whenever the benefits under the Group Contract are changed;
4.Whenever a class of persons is made eligible or is eliminated from eligibility;
5.Whenever the enrollment fluctuates by ten percent (10%) or more;
6.Whenever the Plan is obligated to pay any new taxes, Surcharges or other fees imposed upon or resulting from the Group Contract including, but not limited to, premium taxes or taxes on the Plan’s benefits or services provided under the Group Contract; and
7.Whenever there is a legislative or regulatory mandate or requirement for a change in benefits which would require additional premiums.
C.The Plan is hereby granted discretionary authority to determine, alter, and interpret the provisions, language and Benefits set forth in the Group Contract or the payment of premiums therefor. Any changes in Benefits or premiums shall not affect any Subscriber during the coverage period for which premiums have been paid.
D.All premiums for coverage shall be paid by the Group, as the agent of the Member, to the Plan and shall be payable on or before the Group Contract Date. All further premiums shall be due and payable in advance of and no later than the due date for the coverage period as stated in the Group Billing Statement given to the Group.
E.Failure of the Group to pay premiums or other payment required by the Group Contract to the Plan on or before the due date described above shall automatically and without notice terminate and cancel all coverage for Subscribers at the end of the coverage period for which premiums are paid.
F.If the Group is in default of its obligation to pay premiums or other payment or if any other default has occurred and is continuing, then any indebtedness from the Plan to the Group (including any and all contractual obligations of the Plan to the Group) may be offset and/or recouped and applied toward the payment of the Group’s obligations hereunder, whether or not such obligations, or any part thereof are due the Group.
G.The Plan shall have no liability for any care and services, including Maternity Services, occurring after the date and time of such termination and cancellation, except as described in "Benefits After Termination of Coverage". The Plan reserves the right to reinstate the Group Contract upon such terms and conditions as the Plan determines to be acceptable.
IV.MINIMUM GROUP PARTICIPATION REQUIREMENTS
A.The percentage of enrollment and number of Eligible Persons which must be maintained is:
1.75% of all Eligible Persons, unless specified otherwise on the Benefit Program ApplicationorGroup Application; or
2.two Eligible Persons;
whichever is greater.
B.The aggregate number of Eligible Persons enrolled under the Group Contract and the Employer's alternate Plan Group Contract (if applicable) shall be used in the calculation of the required percentage and number of Eligible Persons which must be enrolled and maintained.
C.A person whose eligibility has been continued, as set forth under "Other Eligibility Provisions", will count toward the required percentage and number of Eligible Persons as described above.
D.The following persons will not count against the required percentage of enrollment as described above:
1.an Eligible Person who is enrolled under the COBRA Continuation Coverage provisions of the Group Contract; or
2.an Eligible Person with coverage through any other health care program.
E.The minimum contribution amount which is required from the Group is 50% of the premium for Member Only (Single) Coverage. Provided however, if the Group offers coverage through BlueLincs HMO, the minimum contribution amount which is required from the Group is 50% of the premium for Member Only (Single) Coverage under the least expensive coverage option.
V.TERMINATION OF THE GROUP CONTRACT
A.The Group Contract will be terminated for the Group's non-payment of the appropriate payment when due or for the Group's failure to perform any obligation required by the Group Contract, as described above.
B.If the Group contracts for, implements and installs another group health care and services program concurrent with the Group Contract, but not underwritten and provided or approved by the Plan, the Group Contract shall automatically and without notice terminate as of the effective date of such other coverage or program.
C.The Plan may request information from the Group on a periodic basis to determine the Group's compliance with the minimum Group participation requirements stated in the Group Contract. The Group Contract may be terminated by the Plan by written notice at the end of the coverage period for which premiums have been paid, or by written notice given thirty-one (31) days prior to such termination by the Plan, for any of the following reasons:
1.The Group fails to provide the information necessary for the Plan to determine the Group's compliance with the minimum Group participation requirements; or