EOC - Erlanger Health System

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Subscribers may take a leave of absence. Subscribers also have to meet these criteria to have continuous Coverage during a leave of absence: a. The Employer continues to consider the Subscriber an Employee, and all other Employee benefits are continued; b. The leave is for a specific period of time established in advance; and c. The purpose of the leave is documented. A Subscriber may apply for COBRA Continuation if the leave lasts longer than allowed by the Employer. 8. The Trade Adjustment Assistance Reform Act of 2002 The Trade Adjustment Assistance Reform Act of 2002 (TAARA) may have added to Your COBRA rights. If You lost Your job because of import competition or shifts of production to other countries, You may have a second COBRA Continuation election period. If You think this may apply to You, check with the Employer or the Department of Labor. 18 Erlanger Health System 2009
COORDINATION OF BENEFITS This EOC includes the following Coordination of Benefits (COB) provision, which applies when a Member has coverage under more than one group contract or health care "Plan." Rules of this Section determine whether the benefits available under this EOC are determined before or after those of another Plan. In no event, however, will benefits under this EOC be increased because of this provision. If this COB provision applies, the order of benefits determination rules should be looked at first. Those rules determine whether the Plan’s benefits are determined before or after those of another Plan. 1. Definitions The following terms apply to this provision: a. "Plan" means any form of medical or dental coverage with which coordination is allowed. “Plan” includes: (1) group, blanket, or franchise insurance; (2) a group BlueCross Plan, BlueShield Plan; (3) group or group-type coverage through HMOs or other prepayment, group practice and individual practice plans; (4) coverage under labor management trust Plans or employee benefit organization Plans; (5) coverage under government programs to which an employer contributes or makes payroll deductions; (6) coverage under a governmental Plan or coverage required or provided by law; (7) medical benefits coverage in group, group-type, and individual automobile “no-fault” and traditional automobile “fault” type coverages; (8) coverage under Medicare and other governmental benefits; and (9) any other arrangement of health coverage for individuals in a group. b. “Plan” does not include individual or family: (1) Insurance contracts; (2) Subscriber contracts; (3) Coverage through Health Maintenance (HMO) organizations; (4) Coverage under other prepayment, group practice and individual practice plans; (5) Public medical assistance programs (such as TennCare sm ); (6) Group or group-type hospital indemnity benefits of $100 per day or less; (7) School accident-type coverages. Each Contract or other arrangement for coverage is a separate Plan. Also, if an arrangement has two parts and COB rules apply to only one of the two, each of the parts is a separate Plan. b. "This Plan" refers to the part of the employee welfare benefit plan under which benefits for health care expenses are provided. The term "Other Plan" applies to each arrangement for benefits or services, as well as any part of such an arrangement that considers the benefits and services of other contracts when benefits are determined. c. Primary Plan/Secondary Plan. (1) The order of benefit determination rules state whether This Plan is a "Primary Plan" or "Secondary Plan" as to another plan covering You. (2) When This Plan is a Primary Plan, its benefits are determined before those of the Other Plan. We do not consider the Other Plan's benefits. (3) When This Plan is a Secondary Plan, its benefits are determined after those of the Other Plan and may be reduced because of the Other Plan's benefits. 19 Erlanger Health System 2009
Page 1 and 2: ERLANGER HEALTH SYSTEM Health Benef
Page 3 and 4: Erlanger Health System 2009
Page 5 and 6: INTRODUCTION This Evidence of Healt
Page 7 and 8: ELIGIBILITY Any Employee of the Emp
Page 9 and 10: EFFECTIVE DATE OF COVERAGE If You a
Page 11 and 12: SUBROGATION AND RIGHT OF REIMBURSEM
Page 13 and 14: BLUECARD/BLUECARD PPO PROGRAM When
Page 15 and 16: CLAIMS AND PAYMENT When You receive
Page 17 and 18: PRIOR AUTHORIZATION, CARE MANAGEMEN
Page 19 and 20: Your concern will be noted and inve
Page 21: the Termination of Coverage Section
Page 25 and 26: (1) First, the Plan of the parent w
Page 27 and 28: of This Plan and such rule states t
Page 29 and 30: II. DESCRIPTION OF THE REVIEW PROCE
Page 31 and 32: DEFINITIONS Defined terms are capit
Page 33 and 34: 24. Employee - A person who fulfill
Page 35 and 36: Investigational Service. If the Med
Page 37 and 38: difference between Billed Charges a
Page 39 and 40: ATTACHMENT A: COVERED SERVICES AND
Page 41 and 42: C. Office Surgery Medically Necessa
Page 43 and 44: injections; (7) fertility drugs, (8
Page 45 and 46: The following Medically Necessary a
Page 47 and 48: d. If You receive Prior Authorizati
Page 49 and 50: d. Items to replace those that were
Page 51 and 52: 3. Three intensive outpatient progr
Page 53 and 54: syringes used in conjunction with i
Page 55 and 56: k. Maintenance Drug - Prescription
Page 57 and 58: EVIDENCE OF COVERAGE ATTACHMENT B:
Page 59 and 60: EVIDENCE OF COVERAGE ATTACHMENT C:
Page 61 and 62: (Family/General Practice, Internal
Page 63 and 64: Other Wellcare Screenings, age 6 an
Page 65 and 66: Schedule of Pharmacy Prescription D
Page 67 and 68: Miscellaneous Limits: In-Network Se
Page 69 and 70: Diagnostic Services and Preventive
Page 71 and 72: Services Received at a Facility Inp
Page 73 and 74:
Organ Transplant Services Organ Tra
Page 75 and 76:
Benefit percentages apply to BCBST
Page 77 and 78:
EVIDENCE OF COVERAGE ATTACHMENT C:
Page 79 and 80:
(Family/General Practice, Internal
Page 81 and 82:
Other Wellcare Screenings, age 6 an
Page 83 and 84:
Schedule of Pharmacy Prescription D
Page 85 and 86:
Miscellaneous Limits: In-Network Se
Page 87 and 88:
the U. S. Department of Labor, or m
Page 89 and 90:
UNIFORMED SERVICES EMPLOYMENT AND R
Page 91 and 92:
MARKETING: Your medical information
Page 93:
www.bcbst.com BENEFIT QUESTIONS? Ca
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EOC - Erlanger Health System

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