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Medical Benefit Determination RequirementsHEALTH FOR LIFE PROGRAMYour enrollment in this Plan includes the “Health For Life Program”. This is a free, voluntary andconfidential program available to you.As an Employee, you may earn incentives for completing a health assessment, biometric screening,and/or other health initiatives. The incentives may be provided for your participation, and potentially alsothat of your Spouse / Adult Benefit Recipient if they are also enrolled on the Plan. The incentives may beprovided as premium credits or Health Savings Account (HSA) seeding dollars should you be enrolled inthe ProvSelect HSA Plan and also have an active HSA.Information on how to earn these dollars can be found at www.providence-healthforlife.com. TheProvidence contributions do not roll forward to the next Plan Year. The Employee and their Spouse/AdultBenefit Recipient, will need to meet the requirements for each new Plan Year. Providence Health &Services reserves the right to alter, delete, cancel, and otherwise change the “Health for Life” program atany time.Western Montana Providence Health & Services - SPD 18Group #2000204 - January 1, 2011
MEDICAL BENEFITSThe following Medical Benefits are payable as stated in the Schedule of Medical Benefits and subject to allterms and conditions of this Plan. Medical Benefits include:1. Charges made by a Hospital for:A. Daily Room and Board in a Semi-Private Room (or private room if no Semi-Private roomis available or when confinement in a private room is Medically Necessary) and generalnursing services, or confinement in an Intensive Care Unit, not to exceed the applicablelimits shown in the Schedule of Medical Benefits.B. Medically Necessary Hospital Miscellaneous Expenses other than Room and Boardfurnished by the Hospital, including Inpatient miscellaneous service and supplies,Outpatient Hospital treatments for chronic conditions and emergency room use for anEmergency only, Physical Therapy treatments, hemodialysis, and x-ray.C. Nursery neonatal units, general nursing services, including Hospital MiscellaneousExpenses for services and supplies, Physical Therapy, hemodialysis and x-ray, care ortreatment of Injury or Illness, congenital defects, birth abnormalities or premature deliveryincurred by a Newborn Dependent.D. Therapy has been prescribed by the speech pathologist or Physician and includes awritten treatment plan with estimated length of time for therapy, along with a statementcertifying all above conditions are met.Treatment rendered for stuttering or for behavioral or learning disorders isexcluded, except as specifically covered for neurodevelopmental therapy.2. Charges made by an Ambulatory Surgical Center when treatment has been rendered.“Ambulatory Surgical Center” (also called same-day surgery center or Outpatient surgery center)means a licensed establishment with an organized staff of Physicians and permanent facilities,either freestanding or as a part of a Hospital, equipped and operated primarily for the purpose ofperforming surgical procedures and which a patient is admitted to and discharged from within atwenty-four (24) hour period. Such facilities must provide continuous Physician and registerednursing services whenever a patient is in the facility. An Ambulatory Surgical Center must meetany requirements for certification or licensing for ambulatory surgery centers in the state in whichthe facility is located.“Ambulatory Surgical Center” does not include an office or clinic maintained by a Dentist orPhysician for the practice of dentistry or medicine, a Hospital emergency room or trauma center.3. Charges made by an Urgent Care Facility when treatment has been rendered.“Urgent Care Facility” means a free-standing facility which is engaged primarily in diagnosing andtreating Illness or Injury for unscheduled, ambulatory Covered Persons seeking immediatemedical attention. A clinic or office located in or in conjunction with or in any way made a part of aHospital will be excluded from the terms of this definition.4. Charges for services and supplies furnished by a Birthing Center.Western Montana Providence Health & Services - SPD 19Group #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 22 and 23: 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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