Plan 98 - Generic

INTRODUCTION

Welcome to the Belvidere Community Unit School District #100 Employee Health and Dental Care Plan. Your Medical Plan contains a PPO (Preferred Provider Organization). The name of this organization along with the address where all medical claims must be filed is shown on your ID card. A “Schedule of Covered Expenses” and an explanation of PPO options are shown on the following pages. Information on the Dental Plan is also included.

Your Medical Plan also includes a Pre-Certification Program through a Utilization Review Organization. The toll-free number for that review organization is shown on the back of your ID card. Failure to follow the guidelines listed below will subject your benefits to a $500 Penalty for Non-Compliance. The penalty does not apply toward any out-of-pocket expense maximum.

If your Physician recommends admission to a Hospital for surgery or any other reason, follow these steps:

1. Notify your Physician that you participate in a Pre-Certification Program. Please note that this applies even if this Plan is secondary under Coordination of Benefits.

2. You or your Physician must call the review firm at least two days before an elective Hospital admission for any reason other than maternity

Maternity admissions should be notified at the time of the admission or by the end of the second work day after the admission. However, scheduled cesarean births and scheduled inducements must be reviewed in advance just like any other scheduled admission. This Plan may not under federal law require that a provider obtain authorization from the Plan for a length of stay of 48 or less hours for a normal delivery or 96 or less hours for a cesarean section.

3. If you have an emergency admission or surgery, certification is required within 2 business days of admission.

The following information will be needed to pre-certify:

Regarding Patient: Regarding Employee:

Name Name

Address Address

Telephone # Telephone #

Date of Birth Date of Birth

Relationship to Employee Sex

Physician’s Name Social Security Number

Physician’s Phone Number Name of Employer

Hospital/Address Name of Plan Supervisor

(Allied Benefit Systems, Inc.)

4. A nurse from the review organization will call your Physician to review the proposed Hospital admission. If admission is determined to be necessary, an assigned length of stay will be determined. If additional days are later thought to be necessary, these additional days must also be pre-certified.

5.

When you or your Physician call to pre-certify a Hospital admission or surgery, the call will be logged so that:

· The hospital can verify that pre-certification has been done and can track expected length of stay.

· The Plan Supervisor can verify that the pre-certification requirements have been met when the claim is received for processing.

Note: Pre-Certification of Hospital admissions assists in determining medical necessity and the best place for treatment. This service, however, does not guarantee payment, which is subject to eligibility and coverage at the time services are rendered.

PENALTY FOR NON-COMPLIANCE

The non-compliance penalty specified in the “Schedule of Covered Expenses” will apply under one or more of the following circumstances: a) pre-certification call is not made according to the instructions on page 3; b) Hospital stay exceeds the amount of days pre-certified; c) patient is admitted as an Inpatient when treatment could have been performed on an Outpatient basis;

This penalty will be applied in addition to any applicable Deductible and will not be applied to any Out-of-Pocket Maximum as specified in the “Schedule of Covered Expenses”. The penalty will be applied to Covered Expenses that were incurred during the days that were not pre-certified.

CASE MANAGEMENT OPTION

If, at any point in the progress of a given medical situation, after having considered the opinions of the Covered Person (and/or his/her legally responsible representatives), the Covered Person’s Physician and/or other medical authorities, the Plan Administrator determines that the benefits of this Plan may be best utilized through the implementation of a Case Management Program, the Plan reserves the right to request that further benefits be provided only under the administration of such a program. However, no Covered Person is required to participate in this program and there is no penalty for failure to participate.

DEFINED TERMS

Defined terms used in this booklet begin with a capital letter. These terms have a special meaning under this Plan and are listed in the “Definitions” section or otherwise referenced with a specific explanation as to their meaning.

MEDICAL CARE BENEFITS

	SCHEDULE OF COVERED EXPENSES
BENEFITS and PROVISIONS			In-Network			Out-of-Network
		Calendar Year Deductible (taken before benefits are payable unless none required).			$200 per person $400 per family
		Additional Deductible of $2,500 per Out-of-Network Inpatient Hospital admission. This additional Deductible does not apply to, and is not affected by, the Calendar Year Deductible or the Out-of-Pocket Maximum
		Out-of-Pocket Maximum per Calendar Year (excludes above Deductibles). After amount is reached, 100% level of benefits applies for that Calendar Year. Co-pays do not apply.			$1,000 per person $2,000 per family		$3,000 per person $6,000 per family
	Lifetime Benefit Maximum $2,000,000 per person* *Each Calendar Year, the lesser of $1,000 or the amount received in benefits will be restored to each Covered Person. The Lifetime Benefit Maximum can be restored in full by providing satisfactory evidence of good health.
	Benefits are subject to a $500 penalty per occurrence (after Deductible) when pre-certification procedures are not followed (see pages 3 - 4)			TO PRE-CERTIFY, CALL THE TOLL-FREE NUMBER ON YOUR ID CARD
	Prescription Drug Card Benefit (up to 34-day supply, unless otherwise stated, through participating pharmacies)			$10 co-pay/Generic, $20/Brand* per prescription, then paid at 100% *See page 12 for details.
	Mail Order Drug Benefit (up to 90-day supply per prescription).			$20 co-pay/Generic, $40/Brand per prescription, then paid at 100%
		Outpatient Surgery (facility and Physician charges) including anesthesia, assistant surgeon and sterilization			100% No Deductible		70%
		Outpatient Diagnostic Services (facility and Physician charges)			100% No Deductible		70%
		Outpatient Accident Benefit (within 72 hours after an accident) (facility and Physician charges)			100% No Deductible		100% No Deductible
		Outpatient Medical Emergency Benefit (facility and Physician charges)			100% No Deductible		100% No Deductible
		Other Outpatient Hospital Services (facility and Physician charges)			90%		70%
		Ambulatory Surgical Center			100% No Deductible		70%
		Second Surgical Opinions			100% No Deductible		70%
		Wellness Care age 16 and over (includes routine physical examination, routine diagnostic tests, x-rays, immunizations and Pap smears) $250 maximum payment per person every other Calendar Year (Does not include routine care listed below)			$10 co-pay per visit, then paid at 100%. No Deductible		Not covered
		Routine Mammogram for Covered Females			No Deductible First $100 – 100% All other expenses – 90%		70%
		Well Child Care to 16^th birthday. Includes immunizations and routine exams (Maximum payment of $500 per person per Calendar Year)			$10 co-pay per visit, then paid at 100%. No Deductible		70%
		Services in Physician’s Office excluding surgery Includes X-rays and lab tests associated with office visit.			$10 co-pay per visit, then paid at 100%. No Deductible		70%
		Other Physician Services including bedside visits while the patient is confined to a health care facility and home visits. Benefits are provided for consultations during an Inpatient confinement in a Hospital or Extended Care Facility. The consultation must be requested by the attending Physician and consist of another Physician’s advice in the diagnosis or treatment that requires special skills or knowledge. Benefits are not available for any consultation done because of Hospital regulations or by a Physician who renders surgery or maternity services during the same admission.			90%		70%
		Professional Ambulance Service, from the city or town in which the Employee or covered Dependent becomes disabled, to and from the nearest Hospital qualified to provide treatment for the accidental bodily Injury or disease. Air ambulance when medically necessary.			90%		90%
		Extended Care Facility if confinement begins with 30 days of discharge from a Hospital			90%		90%
		Hospice Care when the life expectancy of the Covered Person is 6 months or less			90%		90%
		Spinal Manipulation Treatment ($1,000 maximum payment per person per Calendar Year) Visits, treatments, consultations, x-rays, laboratory tests and other diagnostic studies performed in connection with spinal manipulation in a Physician’s office setting, when rendered by a licensed Chiropractor or a Physician			90%		90%
		Outpatient Cardiac Rehabilitation (Maximum of 36 visits per person within 6 months of Hospital admission for myocardial infarction, coronary bypass surgery or percutaneous transluminal coronary angioplasty)			90%		70%
		Outpatient Physical Therapy (Maximum payment of $1,000 per person per Calendar Year)			90%		70%
		Outpatient Speech Therapy (Maximum payment of $1,000 per person per Calendar Year)			90%		70%
		Outpatient Occupational Therapy (Maximum payment of $1,000 per person per Calendar Year)			90%		70%
		Private Duty Nursing Services Nursing services, provided on a one-to-one basis by an actively participating registered nurse or licensed practical nurse who is not providing this service as an employee or agent of a Hospital or other health care facility. Benefits will be provided while the patient is an Inpatient in a Hospital or other health care facility, provided such services could not or are not usually provided by the regular nursing staff. Includes home nursing services when the services cannot be provided by non-professional personnel. Maximum payment of $1,000 per person per month			90%		70%
		Home Health Care Maximum of 100 visits per person per Calendar Year. A visit is a periodic visit by either a nurse or therapist, as the case may be, or four hours of home health aide services			90%		70%
		Physician’s charges for Inpatient Surgery and related services			90%		70%
		Inpatient Hospital Services § Room and board not to exceed the semi-private room rate (if a Hospital has only private rooms, the covered expense is the actual charge for the room) § Necessary services and supplies including an intensive care unit and a cardiac care unit			90%		Additional $2,500 Deductible per admission, then 70%
		Non-surgical treatment of temporomandibular joint dysfunction (“TMJ”) (limited to a $1,000 Lifetime maximum payment per Covered Person)			90%		70%
		Other Covered Services/Items (see following pages)			90% Unless included under a previous category		70% Unless included under a previous category
		Covered Services/Items not available In-Network			Paid at the In-Network level
	Mental Health Services (Mental/Nervous, Alcohol and Drug Abuse) § Co-Insurance levels shown will never be exceeded and patient’s portion of Co-Insurance will not apply toward Out-of-Pocket Maximum. § Includes facility charges and psychiatric service charges of a Physician for nervous, mental or substance abuse disorder treatment subject to the applicable maximum as shown below. § All mental/nervous and substance abuse treatment is subject to a combined Lifetime maximum payment of $10,000 per person.
		Inpatient/Transitional (Pre-certification applies) Performed by a Physician, Psychologist or clinical social worker. Includes psychotherapy, group therapy, psychological testing and/or family counseling (interviews with the patient’s family to obtain information that will help in treating the patient)			90%		70%
		Outpatient performed by a Physician, Psychologist, clinical social worker, Outpatient Substance Abuse Treatment Facility, or Outpatient Department in a Hospital 52 visit maximum per Calendar Year $40 maximum payment per visit			50%		50%

OTHER COVERED SERVICES/ITEMS

Please read previous pages for detailed information regarding the coverage of services/items in and out of network.

Pre-Admission Testing prior to Inpatient surgery, if benefits would have been available for the tests as a Hospital Inpatient. Benefits are considered part of the Inpatient Hospital stay for surgery and will not be provided if the surgery is canceled or postponed

Anesthesia and Its Administration (Inpatient/Outpatient)

Radium and Radioisotope Treatment

Chemotherapy

Shock Therapy

Renal Dialysis if performed in a Hospital, dialysis facility or the patient’s home under the supervision of a Hospital or dialysis facility

Optometry services provided by a licensed Optometrist, if benefits would have been available had such services been performed by a Physician

Dressings, sutures, casts, splints, trusses, crutches, braces, Ostomy, and other medically necessary supplies

Covered Medically Necessary Prescription Drugs if not available through the Prescription Drug Card or Mail Order Programs

Processing and administration of Unreplaced Blood and its components

Purchasing of Prosthetic Appliances used to aid in the function of or to replace all or part of a limb or organ. Replacement or repair when required by pathological change or normal growth

Mastectomy (refer to page 32)

Oxygen and rental of equipment for administration of oxygen; purchase and/or rental of Durable Medical Equipment (up to purchase price)

Allergy Shots (injections), Allergens and Allergy testing

Dental Treatment when rendered by a Physician, Dentist or oral surgeon for a fractured jaw or of accidental Injuries to natural teeth, jaws, cheeks, lips, tongue, roof and floor of the mouth while covered under this Plan after the accident (replacement or repair of a denture not covered); treatment or removal of a tumor or cyst of the jaws, cheeks, lips, tongue, roof and floor of the mouth; excision of exostoses of the jaw and hard palate; external excision and drainage of cellulitis, incisions of accessory sinuses, salivary glands or ducts; reduction, dislocation or excision of the temporomandibular joints; removal of total bony impacted teeth; medical care, services and supplies furnished by a Hospital during Medically Necessary confinement in connection with dental treatment.

Birthing Center: Minimum coverage for a mother and newborn child for the hospital stay following childbirth is 48 hours for a normal vaginal delivery and 96 hours for a cesarean section.

Routine Newborn Care (covered under the mother’s claim for routine Hospital charges. Includes circumcision and one routine Inpatient Physician examination by a Physician who did not deliver the child or administer anesthesia during the delivery)

Diagnostic x-rays and laboratory testing (tests rendered for the dagnosis of symptoms that are directed toward evaluation or progress of a condition, Illness or Injury. Such tests include, but are not limited to, x-rays, pathology servies, clinical laboratory tests, pulmonary funtion studies, electrocardiograms)

Termination of a Pregnancy (elective induced abortion – if legal where performed)

Voluntary Sterilization

Cosmetic Surgery (cosmetic services, supplies or surgery to correct congenital deformities or conditions resulting from accidental injury, scars, tumors or diseases)

Option

2

Services or supplies for the diagnosis and treatment of infertility including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer.

However, coverage for procedures for in vitro fertilization, gamete intrafallopian transfer, or zygote intrafallopian tube transfer shall be required only if:

§ The Covered Person has been unable to attain (after one year of unprotected sexual intercourse) or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments;

§ The Covered Person has not undergone 4 completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then 2 more completed oocyte retrievals shall be covered; and

§ The procedures are performed at medical facilities that conform to the American College of Obstetric and Gynecology guidelines for in-vitro fertilization clinics and to the American Fertility Society minimal standards for programs of in-vitro fertilization.

Benefits will not be provided for:

¨ Services rendered to a surrogate mother for purposes of childbirth

¨ Expenses incurred for cryo-preservation of sperm, eggs and embryos, except for those procedures that use a cryo-preserved substance

Organ or Tissue Transplants for cornea or kidney transplants; also for the following human-to-human organ or tissue transplants: bone marrow, heart, heart/lung, heart valve, muscular-skeletal, parathyroid, liver, lung and pancreas and pancreas/kidney, subject to the following:

¨ Whenever your Physician recommends a heart, lung, heart-lung, liver, pancreas or pancreas-kidney transplant, the pre-certification procedures on pages 3-4 must be followed. You will be provided with names of Hospitals that have approved Human Organ Transplant Programs. No benefits will be provided for any of the above transplants if they are performed at a Hospital that does not have an approved Human Organ Transplant Program.

¨ Benefits will begin no earlier than five days before the transplant surgery and continue for up to 365 days after the procedure. Benefits are provided for all Inpatient and Outpatient covered services related to the transplant surgery.

¨ Benefits will also be provided for the transportation of the donor organ to the location of the surgery. Benefits will be limited to the transportation of the donor organ into the United States or Canada.

In addition to the General Limitations of the Plan, benefits will not be paid for:

¨ Cardiac rehabilitation services when not provided to the recipient within three days after discharge from a Hospital for transplant surgery.

¨ Transportation by air ambulance for the donor or recipient.

¨ Travel time and related expenses required by a service provider.

¨ Investigative drugs.

If both the donor and the recipient have coverage, each will be covered under his/her own Plan.

If the recipient is covered under this Plan, and the donor has no coverage under any other Plan, the donor’s expenses will be covered and will apply to the recipient’s Out-of-Pocket (per Calendar Year) and Lifetime Maximums.

If the donor is covered under this Plan, donor expenses will be covered. If the recipient is not a covered under this Plan, no benefits will be provided for the recipient.

In no event will benefits be paid for experimental or investigational services; or, for treatment not deemed clinically acceptable by (a) the National Institute of Health; or (b) the FDA; or (c) a similar national medical organization of the United States

See “General Limitations” & “General Provisions”

For Additional Coverage Details, Exclusions and Limitations

GENERAL LIMITATIONS

No payment will be made under this Plan for expenses incurred by a Covered Person:

1. for or in connection with an Injury arising out of, or in the course of, any employment for wage or profit;

2. for or in connection with an Illness or Injury for which the Employee or Dependent is entitled to benefits under any Workers’ Compensation or similar law;

3. for charges incurred prior to the effective date of coverage under this Plan or after coverage is terminated, unless an Extension of Benefits applies.

4. in a Hospital owned or operated by the United States Government or for services or supplies furnished by or for any other government unless payment is legally required;

5. for charges which the Covered Person is not legally required to pay or for charges which would not have been made if no coverage had existed;

6. for charges in relation to pre-existing conditions, as defined in this document;

7. which are in excess of Reasonable and Customary Charges (depending on contract provisions, this limitation may not apply to charges from network providers or non-network providers who are utilized as a result of requests or requirements of network providers);

8. for care or treatment which is not Medically Necessary; for procedures, surgical or otherwise, that are specifically listed by the American Medical Association as having no medical value;

9. for routine eye examinations; for eyeglasses or contact lenses, or the fitting of eyeglasses or contact lenses (except as provided under the “Schedule of Covered Expenses”); for eye surgery such as radial keratotomy (unless medical criteria is present that is verified on a statement of Medical Necessity and approved by the Plan); for routine hearing examinations, hearing aids, or the fitting thereof;

10. for custodial care. (Expenses incurred to assist a person in daily living activities are considered costs for custodial care. Costs for medical maintenance services and supplies in connection with custodial care due to age, mental or physical conditions, are not covered if such care cannot reasonably be expected to improve a medical condition.);

11. for charges in connection with Cosmetic Surgery/Treatment, except to correct deformities resulting from Injuries sustained in an accident while covered under this Plan; or due to an Illness such as breast cancer (including specified services related to mastectomy treatment – see definition of “Reconstructive Breast Surgery Coverage”); or to correct a functional disorder (functional disorders do not include mental or emotional distress related to a physical condition); or unless treatment is for correction of a functional abnormal congenital condition;

12. for a Covered Person’s charges resulting from or occurring during the commission of a crime or violation of law by that Covered Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations;

13. for treatment of or to the teeth, the nerves or roots of the teeth (except as stated under the “Schedule of Covered Expenses”); for the repair or replacement of a denture;

14. for charges as a result of active participation in war or any act of war, whether declared or undeclared, or caused during service in the armed forces of any country;

15. for check ups and immunizations, including screening, routine physical examinations and research studies not reasonably necessary to the treatment of an Illness or Injury (except as stated under the “Schedule of Covered Expenses”);

16. for services and supplies received from a medical or dental department maintained by or on behalf of an employer, a mutual benefit association, trustee or similar person or group;

17. for occupational therapy when it is not a constructive therapeutic activity designed and adapted to promote the restoration of useful physical function;

18. for speech therapy when it is rendered for other than the correction of a physical impairment caused by Illness, Injury or congenital deformity;

19. due to an Injury or Illness resulting from attempted suicide while sane or insane, or from intentional self-inflicted Injury;

20. for purchase or rental of personal comfort items or supplies of common use; for purchase or rental of blood pressure kits; exercise cycles; air purifiers; air conditioners; water purifiers; hypo-allergenic pillows; mattresses or waterbeds; escalators; elevators; saunas; steamrooms and swimming pools;

21. for instruction or activities for weight reduction or weight control, including charges for vitamins, diet supplements, or physical fitness programs even if the services are performed or prescribed by a Physician; for surgery or treatment for obesity (including morbid obesity);

22. for special education, counseling, or care for learning deficiencies, discipline problems, social maladjustment or behavioral problems (including impulsive behavior and impulsivity syndrome, attention disorder, conceptual handicap or mental retardation), whether or not associated with a manifest mental disorder or other disturbance (however, the exam and diagnostic tests to determine medical cause of such behavior, and to prescribe appropriate medication for treatment, is covered, as are follow up exams to monitor the effect of the medication);

23. for non-medical expenses such as preparing medical reports, itemized bills or charges for mailing; for training, educational instructions or materials, even if they are performed or prescribed by a Physician; for legal fees and expenses incurred in obtaining medical treatment;

24. for Friday and Saturday admissions unless due to a Medical Emergency or if surgery is scheduled within the 24 hour period immediately following admission;

25. for surgical reversal of elective sterilizations; for contraceptive medications; for sex transformations and related treatment,, including counseling, implants and related hormone treatment;

26. for any form of infertility treatment except according to the provisions and guidelines stated in the Schedule of Covered Expenses;

27. for maintenance occupational, physical or speech therapy;

28. for charges for hypnotism, acupuncture or any type of goal oriented or behavior modification therapy, biofedback, myo-functional therapy or sleep therapy;

29. for services and supplies for human organ or tissue transplants other than those specifically listed in this Plan;

30. for treatment of flat foot conditions and the prescription of supportive devices for such conditions and the treatment of subluxations of the foot or routine foot care;

31. for treatment by a Physician, nurse or licensed therapist if the Physician, nurse or licensed therapist is related by blood, marriage, or by legal adoption to either the Covered Person or a spouse; for treatment provided by any person who ordinarily resides with the Covered Person;

32. for experimental or investigational procedures, drugs or research studies, or any services or supplies not considered legal in the United States, or for treatment not deemed clinically acceptable by (1) the National Institute of Health; or (2) the FDA; or (3) HCFA (Medicare); or (4) the AMA; or a similar national medical organization of the United States;

33. for legend vitamins (except as stated under the Prescription Drug Card benefit); for non-legend vitamins or drugs regardless of being prescribed by a Physician;

34. for blood derivatives that are not classified a drugs in the official formularies;

35.

for any form of medication or treatment not prescribed in relation to an Injury, Illness or pregnancy, unless specifically provided;

36. f

or any expense in excess of any maximum or limit as stated elsewhere in this document;

37. for services or items not covered by a Health Maintenance Organization (HMO) because the Dependent chose not to avail himself or herself to the HMO participating provider;

38. if, on the date coverage under this Plan would otherwise take effect, an Employee is not Actively at Work, or a Dependent (other than a child who is newborn or adopted while this Plan is in effect) is confined in a Hospital as a result of an Illness or Injury, the effective date of coverage is deferred until the Employee returns to active work, or the Dependent is no longer confined;

39. for charges incurred outside the United States if travel to such a location was for the primary purpose of obtaining medical services, drugs or supplies;

40.

for failure to provide any additional documentation or information as may be requested pursuant to the “Procedures For Filing Claims” section of this Plan.

See also “General Provisions”

DEFINITIONS

Certain words and terms used herein shall be defined as follows:

ACTIVELY AT WORK

Shall mean an Employee's continuous, full-time performance of all customary duties of his or her occupation (the number of hours per week required are shown under the Definition of an "Employee") at the Employer's usual place of business, or other business locations to which the Employer requires the Employee to travel throughout the year.

ADMINISTRATOR

The person or entity responsible for the day-to-day functions and management of the Plan. The Administrator may employ persons or firms to process claims and perform other Plan connected services. The Administrator is the Company.

AMBULATORY SURGICAL CENTER

Any private or public establishment with: a) an organized medical staff of Physicians; b) permanent facilities that are equipped and operated primarily for the purpose of performing Outpatient surgical procedures; c) continuous Physician services and registered professional nursing services whenever a patient is in the facility and which does not provide services or other accommodations for patients to stay overnight.

CALENDAR YEAR

That period of time commencing at 12:01 a.m. on January 1st and ending at 12:01 a.m. on the next succeeding January 1st. Each succeeding like period will be considered a new Calendar Year.

CASE MANAGEMENT PROGRAM

A program of medical management typically utilized in situations involving extensive and on-going medical treatment, which provides a comprehensive and coordinated delivery of services under the oversight of a medically responsible individual or agency. Such programs may provide benefits not normally covered under Plan provisions in lieu of in-Hospital treatment.

COMPANY

The Company shall mean Belvidere Community Unit School District #100.

COSMETIC SURGERY/TREATMENT

Surgery or treatment that is intended to improve the appearance of a patient or to preserve or restore a pleasing appearance and does not meaningfully promote the proper function of the body or prevent or treat Illness or disease (except when necessary to improve a deformity arising from, or directly related to, a congenital abnormality, a personal Injury resulting from an accident or trauma, or a disfiguring disease).

COVERED PERSON

A covered Employee or a covered Dependent. No person is eligible for health care benefits both as an Employee and as a Dependent under this Plan. If both spouses are eligible Employees of this Plan, each may enroll individually as an Employee. Only one parent may enroll their mutual Dependent children for coverage under this Plan.

DEDUCTIBLE

The amount of eligible expense incurred in any Calendar Year, which must be satisfied by the Covered Person before benefits are paid.

DIALYSIS FACILITY

A facility other than a Hospital whose primary function is to treat and/or provide maintenance and/or training dialysis on a ambulatory basis for renal dialysis patients and that is properly licensed by the appropriate governmental authority to provide such services.

DEPENDENTS

Spouse of the Employee who is a resident of the same country in which the Employee resides and who is not legally separated or divorced. To be an Employee’s spouse, a person must have met all requirements of a valid marriage contract in the State of marriage of such parties.

Unmarried children from birth to their 19^th birthday who live in the same country in which the Employee resides. The term “child” or “children” means children who reside with the Employee in a parent-child relationship and who are primarily dependent upon the Employee for maintenance and support, including children placed under legal guardianship, children placed for adoption, adopted children or stepchildren. Note that the residency requirement for children may be waived if a) the Employee is obligated by judgment or court decree to pay such child’s medical expenses or to provide medical insurance on behalf of the child (see “Qualified Medical Child Support Order” in “Definitions”), or b) the child is a Full-Time Student as defined below.

Unmarried dependent children are covered to their 23^rd birthday if they are enrolled as Full-Time Students in an accredited educational institution and are dependent upon the Employee for principal support and maintenance. A person continues to be a Full-Time Student immediately after the period of vacation or term break. A person ceases to be a Full-Time Student at the end of the month during which he or she graduates or otherwise ceases to be enrolled and in attendance at the institution on a full-time basis.

A child who is physically or mentally incapable of self-support upon attaining age 19, and covered under the Plan when reaching this age, may be continued under the health care benefits, while remaining incapacitated and unmarried, subject to the covered Employee’s own coverage continuing in effect. To continue a child under this provision, the Company must receive proof of incapacity within 31 days after coverage would otherwise terminate. Additional proof will be required from time to time.

In no event will the term “Dependent include a) a spouse or child on active military duty in the armed forces of any country, or b) a child who is eligible for coverage under this Plan as an Employee, c) a foster child, or d) a grandchild.

DURABLE MEDICAL EQUIPMENT

Equipment that is able to withstand repeated uses, is primarily and customarily used to serve a medical purpose and which is not generally useful to a person in the absence of Illness or Injury.

ELECTIVE SURGICAL PROCEDURE

Any non-emergency surgical procedure which may be scheduled at a patient’s convenience without jeopardizing the patient’s life or causing serious impairment to the patient’s bodily functions and which is performed while the patient is confined in a Hospital as an Inpatient or in an Ambulatory Surgical Center.

EMPLOYEE

All persons who work for the Employer at least 30 hours per week on a Regular Basis who are on the permanent payroll of the Plan Administrator, and teachers employed on a 50% or greater basis who are on the permanent payroll of the Plan Administrator.

EMPLOYER

The Employer shall mean Belvidere Community Unit School District #100.

EVIDENCE OF GOOD HEALTH

Satisfactory proof to the Plan that your health is acceptable for coverage under this Plan. The Plan Supervisor may require, among other things, proof of age and/or a Physician’s report.

EXPERIMENTAL

When referring to a drug, device procedure, or treatment, means the drug, device, procedure, or treatment is limited to research, not proven in an objective manner to have therapeutic value or benefit, restricted to use at medical facilities capable of carrying out scientific studies, or is of questionable medical effectiveness. To determine whether a procedure is experimental, the Plan Supervisor will consider, among other things, commissioned studies, opinions, and references to or by the American Medical Association, the Federal Drug Administration, the Department of Health and Human Services, the National Institutes of Health, the Council of Medical Specialty Societies and any other association or federal program or agency that has the authority to approve medical testing or treatment.

EXTENDED CARE FACILITY

An institution (or a distinct part of an institution) which: (a) provides for Inpatients (1) 24-hour nursing care and related services for patients who require medical or nursing care, or (2) service for the rehabilitation of injured or sick persons; (b) has policies developed with the advice of (and subject to review by) professional personnel to cover nursing care and related services; (c) has a Physician, a registered professional nurse or a medical staff responsible for the execution of such policies; (d) requires that every patient be under the care of a Physician and makes a Physician available to furnish medical care in case of emergency; (e) maintains clinical records on all patients and has appropriate methods for dispensing drugs and biologicals; (f) has at least one registered professional nurse employed full time; (g) provides for periodic review by a group of Physicians to examine the need for admissions, adequacy of care, duration of stay and medical necessity of continuing confinement of patients; (h) is licensed pursuant to law, or is approved by appropriate authority as qualifying for licensing and is also approved by Medicare; (i) is not primarily a place for the aged, drug addicts, alcoholics, mentally retarded persons, or a place for rest, custodial or educational care or for the care of mental disorders.

FULL-TIME STUDENT

Shall mean a dependent child of an Employee who is enrolled and regularly attending an accredited educational institution for the minimum number of credit hours required by that institution to maintain Full-Time Student status.

GENDER NEUTRAL WORDING

A masculine pronoun in this document shall at all times be considered synonymous with a feminine pronoun unless the context indicates otherwise.

HOME HEALTH CARE AGENCY

A public or private agency that is primarily engaged in providing skilled nursing and other therapeutic services and is either (1) licensed or certified as a home health agency by the governing jurisdiction; or (2) certified as a home health agency by Medicare.

HOSPICE

A facility established to furnish terminally ill patients a coordinated program of Inpatient and home care of a palliative and supportive nature. A hospice must be approved as meeting established standards, including any legal licensing requirements.

HOSPITAL

An institution which meets all of the following requirements; (a) maintains permanent and full-time facilities for bed care of resident patients; (b) has a doctor in regular attendance; (c) continuously provides 24 hour a day nursing services by Registered Nurses (R.N.); (d) is primarily engaged in providing diagnostic and therapeutic services and facilities for medical and surgical care of Injuries or Illnesses on a basis other than a rest home, nursing home, convalescent home, or a home for the aged; (e) maintains facilities on the premises for surgery; (f) is operating lawfully as a Hospital in the jurisdiction where it is located; (g) is accredited by the Joint Commission on the Accreditation of Healthcare Organizations or is Medicare approved.

In addition, the term “Hospital” shall mean, as defined by Medicare, a Psychiatric Hospital, which is qualified to participate in and is eligible to receive payments under and in accordance with the provisions of Medicare; or, which meets the following requirements; (a) is licensed by the jurisdiction in which it operates; and (b) is accredited by the Joint Commission on the Accreditation of Healthcare Organizations.

HOSPITAL INTENSIVE CARE/CARDIAC CARE UNIT

Only a section, ward or wing within the Hospital which is distinguishable from other Hospital facilities because it (a) is operated solely for the purpose of providing room and board and professional care and treatment for critically ill patients, including constant observation and care by a Registered Nurse (R.N.) or other highly trained Hospital personnel, and (b) has special supplies and equipment necessary for such care and treatment, available on a standby basis for immediate use.

HOSPITAL SEMI-PRIVATE

The charge by the Hospital for semi-private room and board accommodations or the average semi-private room rate of other Hospitals in the same geographical area if the Hospital does not provide semi-private accommodations.

ILLNESS

Only non-occupational sickness, disease, mental infirmity or pregnancy, all of which require treatment by a Physician.

INJURY

Only non-occupational bodily Injury which requires treatment by a Physician. This definition refers to only accidental bodily injury caused by an external force, occurring while this Plan is in effect.

INPATIENT

A Covered Person shall be considered to be an “Inpatient” if he is treated at a Hospital or Extended Care Facility and is receiving room and board and general nursing care as a bed patient.. The term “Inpatient” shall also apply to those situations where “partial hospitalization” (defined as an on-going period of treatment involving full use of Hospital facilities excepting only room and board service) is recommended by the patient’s Physician as an alternative to Hospital confinement.

INVESTIGATIVE OR INVESTIGATIVE SERVICES AND SUPPLIES

Procedures, drugs, devices services and supplies that:

· Are provided or performed in special settings for research purposes or under a controlled environment and that are being studied for safety, efficiency and effectiveness;

· Are awaiting endorsement by the appropriate National Medical Specialty College or federal government agency for general use by the medical community at the time they are rendered to the patient; and

· Specifically with regard to drugs, combination of drugs and/or devices, are not finally approved by the Federal drug Administration at the time used or administered.

LATE ENROLLMENT

An enrollment which takes place other than during the first period during which an individual was eligible for coverage.

LIFETIME

Shall mean, “while covered under the Plan”. Under no circumstances will the word “Lifetime” mean “during the lifetime of the Covered Person”.

MAINTENANCE THERAPY

Occupational, physical or speech therapy administered to maintain a level of function at which no demonstrable and measurable improvement of a condition will occur.

MEDICAL EMERGENCY

The initial outpatient care of a medical condition that manifests itself by sudden and acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in:

1. Serious jeopardy to the person’s health or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child;

2. Serious impairment to the person’s body functions; or

3. Serious dysfunction of one or more of the person’s body organs or parts.

MEDICALLY NECESSARY

Health care services, supplies or treatment which, in the judgment of the attending Physician, is appropriate and consistent with the diagnosis and which, in accordance with generally accepted medical standards, could not have been omitted without adversely affecting the patient’s condition or the quality of medical care rendered.

MEDICARE

The medical care benefits provided under Title XVIII of the Social Security Act of 1965 as subsequently amended.

MENTAL DISORDER

A condition that is classified as neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disorder of any kind. To be considered a Mental Disorder under this Plan, the condition must be defined as such in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association that is current as of the date services are rendered.

NAMED FIDUCIARY

The person or entity who has the complete authority to control and manage the operation and administration of the Plan. The Named Fiduciary for the Plan is the Employer, who is the sponsor of this Plan.

In exercising its fiduciary responsibilities, the Employer shall have the discretionary authority to determine eligibility for benefits, review denied claims for benefits, interpret Plan provisions, construe disputed Plan terms and select managed care options. The Employer shall be deemed to have properly exercised such authority unless it has abused its discretion by acting arbitrarily and capriciously.

Any other individual or entity exercising any discretionary authority with respect to the Plan shall also be deemed to have properly exercised such authority unless it has abused its discretion by acting arbitrarily and capriciously.

OUTPATIENT

A Covered Person shall be considered to be an “Outpatient” if he is receiving treatment not as an Inpatient.

OUTPATIENT SUBSTANCE ABUSE TREATMENT FACILITY

An institution that provides a program for diagnosis, evaluation and effective treatment of alcoholism and/or substance abuse; provides detoxification services needed with its effective treatment program; provides infirmary-level medical services that may be required; is at all times supervised by a staff of Medical Doctors; prepares and maintains a written plan of treatment for each patient, based on the patient’s medical, psychological, and social needs and supervised by a Medical Doctor; and meets state licensing standards.

PHYSICIAN

A Physician who is duly qualified and licensed by the state in which he is resident to practice medicine, perform surgery and to prescribe drugs, or who is licensed to practice as a dentist, podiatrist, chiropractor, psychologist, social worker or practitioner of healing arts, and who is practicing within the scope of his license.

PLAN

This is a group health plan. The benefits and provisions for payment of same as described herein are called the Belvidere Community Unit School District #100 Employee Health Care Plan.

PLAN ADMINISTRATOR

The entity responsible for the overall management of the Plan. The Plan Administrator is Belvidere Community Unit School District #100.

PLAN SUPERVISOR

The entity providing consulting services to the Company in connection with the operation of the Plan and performing other functions, including processing of claims. The Plan Supervisor is Allied Benefit Systems, Inc., P. O. Box 909786‑60690, Chicago, IL 60690.

PLAN YEAR

The 12-month period defined under the section “General Provisions”, sub-section “Administration of the Plan” in this document.

PRE-EXISTING CONDITIONS LIMITATION

A limitation or exclusion of coverage due to a physical or mental condition that existed before the individual’s coverage date. To limit or exclude coverage for such a condition, the individual must have sought medical advice, diagnosis, care or treatment during the 12 month period prior to his or her coverage date, and the expenses incurred in regard to such condition must have occurred prior to such person completing 90 days of consecutive coverage under the Plan.

QUALIFIED MEDICAL CHILD SUPPORT ORDER

Any state court judgment, decree, or order that gives a Covered Person’s child a right to be enrolled in This Plan and the right to receive benefits under This Plan if the judgment, decree, or order meets certain specific requirements, including:

1. The name and last known mailing address of the Covered Person and each alternate recipient covered by the order;

2. A reasonable description of the type of coverage or benefit to be provided to the alternate recipient;

3. The period to which the medical child support order applies; and

4. Each plan to which the order applies.

A QMCSO cannot require the plan to provide any type or form of benefit, or any other option, not otherwise available under This Plan except to the extent mandated by Section 1908 of the Social Security Act.

ERISA preemption of State laws does not apply to QMCSO and provisions of State laws requiring medical child support. Group health plans may not deny enrollment of a child under the health coverage of the child’s parent on the ground that the child is born out of wedlock, not claimed as a dependent on the parent’s tax return, or not in residence with the parent or in the applicable service area. Additional information concerning QMCSO procedures are available from the Plan Administrator at no charge upon request.

REASONABLE AND CUSTOMARY

The usual charge made by a Physician or supplier of services or supplies which shall not exceed the general level of charges made by others rendering or furnishing such services or supplies within the area in which the charge is incurred for Illnesses or Injuries comparable in severity and nature to the Illness or Injury being treated. The term “area” as it would apply to any particular service, medicine, or supply means a county or such greater area as is necessary to obtain a representative cross section of level of charges.

RECONSTRUCTIVE BREAST SURGERY COVERAGE

Charges for reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses (implants, special bras, etc.) and treatment of physical complications at all stages of the mastectomy, including lymphedemas for a Covered Person who is receiving benefits under this Plan in connection with a mastectomy and who elects breast reconstruction. The Plan will provide coverage in a manner determined in consultation with the Covered Person and his or her attending Physician. The coverage will be subject to the terms of the Plan established for other coverage under the Plan, including the annual deductible and coinsurance provisions.

REGULAR BASIS

A basis whereby an Employee is regularly employed as defined under the definition of “Employee.” Such work may occur either at the usual place of business of the School District or at a location to which the business of the School District requires the Employee to travel and for which he or she receives regular earnings from the School District.

SECOND SURGICAL OPINION

Shall mean a written statement on the necessity for the performance of a covered surgical procedure. This Second Surgical Opinion must be given by a board-certified specialist who, by the nature of the Physician’s specialty, qualifies the Physician to consider the surgical procedure being proposed and who is otherwise not associated with the surgeon who initially recommended the surgery.

TOTAL DISABILITY (TOTALLY DISABLED)

INTRODUCTION

PENALTY FOR NON-COMPLIANCE

CASE MANAGEMENT OPTION

DEFINED TERMS

PPO OPTION

MEDICAL CARE BENEFITS

SCHEDULE OF COVERED EXPENSES

OTHER COVERED SERVICES/ITEMS

PRESCRIPTION DRUG CARD BENEFIT

MAIL ORDER DRUG BENEFIT

GENERAL LIMITATIONS

MEDICARE ELIGIBLE COVERED PERSONS

BENEFITS FOR MEDICARE ELIGIBLE COVERED PERSONS

PRE-EXISTING CONDITIONS LIMITATION

PAYMENT PROVISIONS

OUT-OF-POCKET MAXIMUM

DEFINITIONS