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MEDICAL BENEFIT DETERMINATION REQUIREMENTSPLAN OPTIONSEligible Employees may elect during the Initial Enrollment Period or the Open Enrollment Period toparticipate in either the ProvPreferred PPO Option or the ProvSelect HSA Option.Employees must indicate their Plan Option choice on the enrollment form. Plan Options cannot bechanged during the Benefit Period once an election is made.The Deductible, Benefit Percentage and Out-of-Pocket Maximum provisions apply to all benefits accordingto the Plan Option elected by the Employee.ELIGIBLE SERVICES, TREATMENTS AND SUPPLIESServices, treatments or supplies are eligible for coverage if they meet all of the following requirements:1. They are administered, ordered or provided by a Physician or other eligible Licensed Health CareProvider; and2. They are Medically Necessary for the diagnosis and treatment of an Illness or Injury or they arespecifically included as a benefit if not Medically Necessary; and3. Charges do not exceed the Maximum Eligible Expense of the Plan or Procedure Based Limit,whichever is applicable; and4. They are not excluded under any provision or section of this Plan.Treatments, services or supplies excluded by this Plan may be reimbursable if such charges areapproved by the Plan Administrator prior to beginning such treatment. Prior approval is limited tomedically accepted non-experimental or investigational treatments, services, or supplies, which,in the opinion of the Plan Administrator, are more cost effective than a covered treatment, serviceor supply for the same Illness or Injury, and which benefit the Covered Person.DEDUCTIBLE (ProvSelect PPO)The Deductible applies to Expenses Incurred during each Benefit Period, unless specifically waived, but itapplies only once for each Covered Person within a Benefit Period. Also, if members of a Family havesatisfied individual Deductible amounts that collectively equal the Deductible per Family, as stated in theSchedule of Medical Benefits, during the same Benefit Period, no further Deductible will apply to anymember of that Family during that Benefit Period. An individual Covered Person cannot receive credittoward the Family Deductible for more than the Individual Annual Deductible as stated in theSchedule of Medical Benefits.Western Montana Providence Health & Services - SPD 16Group #2000204 - January 1, 2011
Medical Benefit Determination RequirementsDEDUCTIBLE (ProvSelect HSA)Single coverage means only the Employee is covered under the Plan. Family coverage means theEmployee and any dependent(s) are covered under the Plan.The single Deductible applies to Expenses Incurred during each Benefit Period. For single coverage, nofurther Deductible will apply to expenses during that Benefit Period after the single Deductible is met.The Family Deductible applies to Expenses Incurred during each Benefit Period for the members of aFamily, unless specifically waived as stated in the Schedule of Medical Benefits. After satisfaction of theFamily Deductible, no further Deductible will apply to Expenses Incurred for any member of that Familyduring that Benefit Period. No benefits will be payable to any Family member until satisfaction of theFamily Deductible unless specifically waived as stated in the Schedule of Medical Benefits.BENEFIT PERCENTAGEThe Benefit Percentage is stated in the Schedule of Medical Benefits. The Plan will pay the BenefitPercentage of the Maximum Eligible Expense or the Procedure Based Limit indicated.OUT-OF-POCKET MAXIMUM (ProvSelect PPO)The Out-of-Pocket Maximum, per Covered Person or Family, whichever is applicable, is stated in theSchedule of Medical Benefits and includes amounts applied toward the Deductible and amounts in excessof the Benefit Percentage paid by the Plan. Expenses Incurred in a single Benefit Period after satisfactionof the Out-of-Pocket Maximum per Covered Person or per Family, whichever is applicable, will be paid at100% of the Maximum Eligible Expense or Procedure Based Limit for the remainder of the Benefit Period.An individual Covered Person cannot receive credit toward the Family Out-of-Pocket Maximum formore than the Individual Out-of-Pocket Maximum as stated in the Schedule of Medical Benefits.OUT-OF-POCKET MAXIMUM (ProvSelect HSA)Single coverage means only the Employee is covered under the Plan. Family coverage means theEmployee and any dependent(s) are covered under the Plan.The Out-of-Pocket Maximum is stated in the Schedule of Medical Benefits and includes amounts appliedtoward the Deductible and amounts in excess of the Benefit Percentage paid by the Plan. ExpensesIncurred in a single Benefit Period after satisfaction of the Out-of-Pocket Maximum will be paid at 100% ofthe Maximum Eligible Expense or Procedure Based Limit for the remainder of the Benefit Period.APPLICATION OF DEDUCTIBLE AND ORDER OF BENEFIT PAYMENTDeductibles will be applied to Expenses Incurred in the chronological order in which they are adjudicatedby the Plan. Expenses Incurred will be paid by the Plan in the chronological order in which they areadjudicated by the Plan. The manner in which the Deductible is applied and Expenses Incurred are paidby the Plan will be conclusive and binding on all Covered Persons and their assignees.CHANGES IN COVERAGE CLASSIFICATIONA change in coverage that decreases a benefit of this Plan will become effective on the stated effectivedate of such change with regard to all Covered Persons to whom it applies.Western Montana Providence Health & Services - SPD 17Group #2000204 - January 1, 2011
Page 2: Western Montana Providence Health &
Page 9 and 10: SCHEDULE OF MEDICAL BENEFITS - PROV
Page 11 and 12: Schedule of Medical Benefits - Prov
Page 13 and 14: SCHEDULE OF MEDICAL BENEFITS - PROV
Page 16 and 17: Schedule of Medical Benefits - Prov
Page 18 and 19: Pharmacy BenefitWhen Primary Covera
Page 20 and 21: Pharmacy BenefitPRIMARY COVERAGE UN
Page 24 and 25: Medical Benefit Determination Requi
Page 26 and 27: Medical Benefits5. Charges made by
Page 28 and 29: Medical Benefits15. Charges for dru
Page 30 and 31: Medical BenefitsGENETIC AND INFERTI
Page 32 and 33: Medical BenefitsPREVENTIVE CARE“P
Page 34 and 35: Medical Benefits3. Services provide
Page 36 and 37: Medical BenefitsBody Mass Index (BM
Page 38 and 39: Pre-Authorization6. A letter of med
Page 40 and 41: Hospital Admission CertificationCON
Page 42 and 43: Medical Benefit Exclusions10. Charg
Page 44 and 45: GENERAL PLAN EXCLUSIONS AND LIMITAT
Page 46 and 47: General Plan Exclusions and Limitat
Page 48 and 49: Coordination of Benefits“Plan”
Page 50 and 51: Coordination of Benefits3. For Cove
Page 52 and 53: Procedures for Claiming Benefits1.
Page 54 and 55: Procedures for Claiming Benefits2.
Page 56 and 57: Eligibility ProvisionsD. The ABR is
Page 58 and 59: EFFECTIVE DATE OF COVERAGEAll cover
Page 60 and 61: Effective Date of CoverageD. Placem
Page 62 and 63: QUALIFIED MEDICAL CHILD SUPPORT ORD
Page 64 and 65: FAMILY AND MEDICAL LEAVE ACT OF 199
Page 66 and 67: Family and Medical Leave ActENFORCE
Page 68 and 69: Termination of Coverage7. The date
Page 70 and 71: CONTINUATION COVERAGE AFTER TERMINA
Page 72 and 73:
Continued Coverage After Terminatio
Page 74:
Continued Coverage After Terminatio
Page 77 and 78:
COVERAGE FOR A MILITARY RESERVISTTo
Page 80 and 81:
Recovery/Reimbursement/SubrogationT
Page 82 and 83:
PLAN ADMINISTRATIONPURPOSEThe purpo
Page 84 and 85:
CREDITABLE COVERAGE PROCEDURESCERTI
Page 86 and 87:
General ProvisionsWORKERS' COMPENSA
Page 88 and 89:
General DefinitionsBENEFIT PERCENTA
Page 90 and 91:
General DefinitionsCUSTODIAL CARE
Page 92 and 93:
General Definitions“Reliable Evid
Page 94 and 95:
General DefinitionsLATE ENROLLMENT
Page 96 and 97:
General Definitions9. Are approved
Page 98 and 99:
General DefinitionsPREVENTIVE CARE
Page 100 and 101:
General DefinitionsTOTAL DISABILITY
Page 102 and 103:
ERISA Statement of RightsIf you hav
Page 104 and 105:
HIPAA Privacy and Security Standard
Page 106:
Plan Summary9. IDENTIFICATION NUMBE
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