Brown v. Google, Inc. et al

Filing 32

Attachment 1
DECLARATION of Sue Wuthrich in Opposition to 16 MOTION to Remand filed byMarissa Mayer, Google, Inc.. (Attachments: # 1 Exhibit A (Part 1 of 2)# 2 Exhibit A (Part 2 of 2)# 3 Exhibit B# 4 Exhibit C# 5 Exhibit D# 6 Exhibit E# 7 Exhibit F (Part 1 of 2)# 8 Exhibit F (Part 2 of 2))(Related document(s)16) (Burror, Heather) (Filed on 6/24/2005)

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Brown v. Google, Inc. et al Doc. 32 Att. 1 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 1 of 31 Exhibit A (Part Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 2 of 31 Blue Shield ofCaJifomia Access+ HMO~ ~~I: ~~r~~!r~fjf~. Blue Shield Combined Evidence of Coverage and Disclosure Form Google Inc. Effective Date: July 1, 2004 Visit us at Group An Ir\CIependent Member of the Blue Shield Assodatlon Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 3 of 31 Combined Evidence of Coverage and Disclosure Form Google Inc. Access+ HMO Plan 10 Effective Date: July 1, NOTICE This Evidence of Coverage and Disclosure Form booklet of your Blue Shield health Plan. Please read this Evidence of Coverage and Disclosure Form stand which services are covered health your Plan. If you or your dependents have special health care needs, you should read carefully booklet. . tions of the booklet that apply to those needs. If you have questions about the Benefits of your Plan, or if you would like additional information, please contact Blue Shield Member PLEASE NOTE Some hospitals antJ other providers do not provide one or. be covered under your Plan contract and that you or your need: family planning; contraceptive services, ~cludingemergency contraception; sterilization, including tubal ligation at the tiine of labor and more information before you practice association, or clinic, or call the health Plan at Blue Shield' s Member Services telephone number listed at the back of this booklet to you need~ Ivno (1104) Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 4 of 31 The Blue Shield Access+ HMO Member nUl of Rights As a Blue Shield Access+ HMO Plan Member, you have the right to: 1. Receive considerate and respect for personal privacy and dignity. the effects these have on your daily living. 2. Receive ices available to you, including a clear explanation of how to obtain them. 3. Receive 11. Have confidential when disclosure is required by law or mitted in writing by you. tice, you have the right to review your medical record with your Personal Physician. about your' rights and responsibilities. 4. Receive HMO Health Plan, the you, the Physicians and other 12. Communicate with and receive from Member Services in a can Understand. available to care for you. 5. Select a hislher team of health workers to provide or 13. Know about any transfer to another Hospi- . tal, including arrange for all the care that you need. transfer is necessary and any available. 14. Obtain a referral from your Personal Physician for a second opinion. 6. ' Have reasonable access to appropriate medical services. 7. decisions regarding your medical care. the extent permitted by law, you also have the right to refuse treatment. 8. Receive from your 15. Be fully grievance procedure and understand how to use it without fear of interruption of health care. standing of your medical condition and any proposed appropriate or sary treatment alternatives, including available successloutcomes information, 16. Voice complaints or Access+ HMO Health Plan or the care provided to you and present your grievance in person to Blue Shield if you choose to do so. cost or benefit coverage, so you can make an informed decision before you ment. 9. Receive preventive 17. Participate in establishing Public the Blue Shield Access+ HMO, as outlined in your Evidence of sure Form or Health Service Agreement. ii- .. ":': " ' .. -. . .. . Page 5 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 The Blue Shield Access+ HMO Member Responsibilities As a Blue Shield Access+ HMO Plan Member, you have the responsibility to: 1. Carefully read HMO materials enrolled so you understand ho\y to use your Benefits and how to strong partnership based on and coo~ minim1"7.e your out of pocket costs. Ask sary. You have the the provisions Of your Blue Shield Access+ HMO membership as explained in the Evidence of Coverage and Disclosure Form or 9. Help Blue Shield Health Service Agreement ' 2. Maintain your good current medical records JJy providing timely information regarding changes in family status and other health plan coverage. ness by making positive health choices and seeking appropriate care when it is needed. ~Provide, to the extent possible, information . . that 10. Notify Blue Shield as soon as possible if you are billed inappropriately or if you have any complaints. provide appropriate care for you. Follow the treatment plans mid instructions . you and your Physician have agreed to and 11. Select a Personal Physician for your newborn before birth, when possible, and notify Blue Shield as soon as you have made this selection. ; consider the potential . refuse 12. Treat all reconup.endations. 5. Ask courteously as partners in good health care. 13. Pay your Dues , Copayments and charges for non-covered services on time. and make certain that you explanations and instructions you are given. 6. Make and inform the Plan Physician ahead of time when you must cancel. 14. For all Mental Health and substance abuse Services, follow the treatment plans and instructions agreed to by you and the Mental Health Services Administrator (MHSA) and obtain prior Emergency Mental Health and abuse Services. iii- :........ ................................... ............ . .. Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 6 of 31 Table' of Contents Section Title Page Access+ lIMO Summary of Benefits............ ;................... ........... 1 Your Introduction to the Blue Shield Access+ HMO Health Plan........................................ 9 II. Evidence of Coverage and Disclosure Form.........................................~........................... 10 . Choice of Physicians and Providers ............... IV. How to Use Your Health Plan......................................................~.................................... 12 Plan Benefits. VI. VB. Exclusions and Limitations....... .............................. ...... Plan Service Area and Eligibility ...................................................................................... 38 vm. IX. Duplicate Coverage, Third Party Liability and Coordination of Benefits......................... 41 Individual Conversion Plan and Group Continuation Coverage....................................... 44 Termination of Benefits and Cancellation Provisions ...................................................... 51 XI. Member Services. ... xu. XIII. Grievance Process....... ........... Other Provisions. ....... ......... Definitions. .................. ................. ............................... ....... ......... XIV. Supplement A - Outpatient Prescription Drugs............................................................................ 67 Supplement B - Inpa~ent Substance Abuse Treatment................................................................ 73 Supplement C - Acupuncture and Chiropractic Services Supplement D - Additional Infertility Services............................................................................ 77 iv- Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 7 of 31 PART I. INTRODUCTION ) This Blue eligible Subscribers and limitations. and exclusions oftms Group Health . The Evidence of Coverage PART II. DEFINITIONS In addition to the provisions contained in Disclosure Fonn , the following provisions apply to this Group Health Service Contract: Employee - (1) an Employer, whose nonnal work week is at perfonned at the Employer s regular places of business; or (2) a sole proprietor or partner time basis in the conduct of the business of the , and whose duties in such , in the Employer s business and who partnership engaged on a full-time basis , at least 24 hours per week is included as an is ineligible for coverage time, temporary, or is employed on a substitute basis. , an individual (H11305/EE.) Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 8 of 31 PART A. In addition to the provisions Disclosure Form, the following provisions apply to this Group Health Service Contract: I. The determined as follows: a. individual in s this Contract replaces a Contract between Blue Shield and the Employer, the Employer on the effective date of this Contract who s previous Contract on the date Subscriber of Blue immediately preceding the effective date of this Contract, who lives and/or Plan Service Area is eligible on the effective date of this Contract. th~~f b. , except as provided in paragraph a. above, shall be eligible to date of hire. , the c. If associated Employer shall be treated as the effective date of this Contract for the determining the date of eligibility of the Employees of such Employer. The date of eligibility of a foimer Employee , who has been re-employed , shall be detennined as follows: The Employee s period of service included in the determination of his date of eligibility, provided: he has resumed active work within 6 months after such tennination; b. if resumed active work within the time set by law for reinstatement of employment if tennination was due to ceasing to be disabled; otherwise he shall be considered as an date he resumed work and shall be eligible specified in. 1.b. 3. , and if an Employee transfers from such ineligible class to an eligible class, he shall be considered as having entered the employ Employer on the date of such transfer. Service in an ineligible class shall not be included determination of the date of eligibility. Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 9 of 31 2. For For all Services other than Mental Health substance abuse- . Services. For ices Blue Shield of California has contracted with the Plan s Mental Health Services Administrator (MHSA). The MHSA Members may con~~t the Member Services Department by telephone, letter or online to a review of an initial determination concerning a claim or service. Members may contact the Plan at the telephone number as noted on the last page questions about Mental Health and abuse Services, MHSA Participating Providers, or Mental Health and substance abuse Benefits. You this booklet. If the telephone inquiry to Member Services does not resolve. the question or issue to . the Member's satisfaction, the Member may re- may contact theMHSA at the or address which appear below: 877-263-9952 quest. a grievance at that-time, which the Member Services Representative will initiate on the Member s behalf. US Behavioral Health Plan California' 3111 Camino Del Rio North, Suite 600 San Diego, CA 92108 The ?v.IHSA can answer many questions over the The Member may also initiate a Grievance submitting a letter or a Form , The Member may request this fo:rm' from Member Services. The completed form should be submitted to Member Services at the address telephone. Note: The MHSA has established a procedme for our Members to request an expedited decision. A Member, Physician, or representative of a Member may request an expedited decision when the noted on the last page this booklet. The Member may also submit the grievance online by visiting our web site at http://www. routine decision. making process might seriously jeopardize the life or when the Member is . The .?v.IHSA shall make Member and Physician within 72 hours following the receipt of the request. An may involve admissions, continued stay, or other Blue Shield will acknowledge receipt of a grievance within 5 calendar days. Grievances are resolved within 30 days. The grievance system allows Members to file grievances for at least 180 days following any incident or action that is the subject of the Member s dissatisfaction. See the previous Member Services section for information on the expedited decision process. healthcare services. If you would information regarding the expedited decision pro- For all Mental Services- cess, or if you qualifies for an expedited decision, please contact the MHSA at the number listed above. Members may contact the MHSA by telephone letter or online to request a review of an initial determination concerning a XII. GRIEVANCE PROCESS . Members may contact the MHSA at. the number as noted below. Blue Shield of California has ance tracking Members ' grievances with Blue Shield of California. to the MHSA' s Member does not Member s satisfaction, the Member may request a grievance at that time , which the Member Services Representative will initiate on the Member behalf. The Member may also initiate a submitting a letter or a Grievance 54- ~~~. "j\!'. .);, . Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 10 of 31 Form . The Member may request this form from the MHSA' s Member Services Department. Member wishes, the MHSA' s Member staff will assist in completing the Grievance Form. Completed gri~vance forms must be mailed to the request external review; however, if your matter would qualify for an scribed above or involves a determination that the requested service is experimenta1linvestigational, you may immediately request an external review following receipt of notice of MHSA at th~ address provided ber may also submit the online by visiting initiate this review by completing an application for external review, a copy of which can be obtained by contacting Member partment of Managed Health Care will review the 1-877-263-9952 US Behavioral Health Plan California Aim: Customer Service P. O. Box 880609 San Diego, CA 92168 application and, if the request qualifies for external review, will select an external review agency and have your records The MHSA will' an~e within 5 calendar solved within 30 days. The grievance system allows Members to file days following any incident or action that is the subject of the Member' s dissatisfaction. See the whether the care is Medically Necessary. You may choose to submit additional specialist for an external review agency for review. There cost to you for this external review. You 'and yoUr physician will receive Copies of the opinions the external review agency. The decision of the external review agency is binding on .Blue Shield; if the external reviewer determines that the service is Medically NecessarY, Blue pr~vious Member ..4:, tion on the expedited decision process. NOTE: If your Employer s health Plan is governed by the' Employee Retirement Income Secu- promptly arrange for the service to be provided or the claim in dispute to be paid. This external review process is in rity. Act ("ERISA"), you may have the right to bring a civil ERISA if all required reviews of your claim have proved. been comp~eted. and your claim has not been ap- dures or remedies available to you and is completely voluntary on your part; you ' ~e gated to request external review. However, failure to participate in external For aU Services- you to give up any statutory right to pursue legal action against Blue Shield regarding the disputed service. For more information ternal review process, or to request an application form, please contact Member Services. EXTERNAL INDEPENDENT MEDICAL REVIEW . If your which coverage was denied by Blue Shield or by a contracting provider in whole or in part on the XIII. DEPARTMENT OF MANAGED HEALTH CARE grounds that the service is not sary or is experimental/investigational (including the exterruil review available under the Friedman- REVIEW Knowles Experimental Treatment Act of you may choose to make a request to .the Department of Managed Health Care to have the matter ~ubmitted to an independent agency for external review in accordance The Califpmia Care is responsible for regulating health care service plans. If you health Plan, you should :first telephone yourhea1th normally must first request an appeal from Blue Shield and wait for at least 30 55- Plan at the number provided on the last page of this booklet and use your health Plan s' grievance process before contacting the Department Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 11 of 31 . ing grievance procedure does not prohibit any terests in Blue Shield. The names of the members of the Board .0fDirectors 'may be obtained from: - potential legal rights or available to you. . If you need help with a grievance involving an emergency, a been satisfactorily resolved by your health Plan, or Director, Consumer Affairs Blue Shield of California ' 50 Beale Street a grievance that has remained unresOlved for more than 30 days, you may call the Department for assistance. You may also . be pendent Medical Review (IMR). If you are eligible the IMR process will provide an impartial for review of medical decisions made by a health plan related to the medical service or treatment, coverage ' decisions for S~ 1.05 Phone Number: 1-415-229- 5104 Please follow the following proc~dure: . 1. Your ments should be submitted in writing Director, Consumer Affairs, at the above ad- ments that are experimental or nature and payment disputes for emerg~cy gent medical services. The Department also has a toll-free telephone and a TDD line and speech impaired. The Deparbnent' s Internet dress, who will acknowledge receipt of your letter; 2. Your name, . scn'ber included with each communication; 3. The . Web site ( has complaint foDDS, IMR application forms and instruc- tions online. will be readily understood. Submit all relevant information and reasons for the policy issue with your letter; 4. Policy In the event that Blue Shield should cancel or refuse to renew the enrollment for' you or your De- pendents and you feel that such action was due to health or utilization of Benefits, you or your Dependents may request a review by the Department of Managed Health Care Director. PuBuc POliCY agenda items for meetings of the Board rectors. Minutes of Board flect decisions on public policy issues that were considered. If you have initiated a policy issue, appropriate extracts of the minutes will be furnished to you within 10 business days after the minutes have been approved. CONFIDENTlALlTY OF PERSONAL AND INFORMATION This procedure enables you to participate in establishing public policy of Blue Shield of Califor- nia. It grievance procedure~ complaints, inquiries or requests for information. Public policy means acts performed by a Plan or its employees and staff to assure the comfort, dignity, and convenience of patients who rely on the Plan s facilities to provide health care services to them, their families, and the public (Health and Safety Code, Section 1369). Blue Shield of California protects the confidentiality/privacy of your personal and health information. Personal and health information includes both medical' information and fiable information, such as your name, address, telephone number, or Blue Shield win not without your authorization, by law. except as permitted AHem one Shield is comprised of Subscribers employees, providers, contract brokers and who do not have financial in56- A STAlEMENT DESCRIBING BLUE SHIELD' POLICIES AND :.! . ':~ . ." Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 12 of 31 SERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS A V sary care. The Hospitals in the Plan network pro- FURNISHED TO YOU UPON REQUEST. Blue Shield' s policies and procedures regarding our confidentiality/privacy practices are Notice of Privacy Practices , which you may obtain either by calling the Member Services Department at the nmnber provided on the last page oftbis booklet, or by accessing Blue Shield of California s internet site located at vide access to 24-hour emergency services. The list of the Hospitals, Physicians and Participating Hospice Agencies in your Service Area indicates the location and phone numbers of these Services at the number provided on the last page of this booklet for information on Physician Health Care Practitioners in your Personal Physician Service Area. printing a copy. If you are concerned that Blue Shield may have violated your you disagree with a decision we made about access to your personal and health information, you may contact us at: Correspondence Address: BI,!e Shield of California Privacy Official For Urgent Services when you are outside California or the United States, you simply call tollfree 1-800-810-BLUE (2583) 24 hours a day, 7 days a week. We will identify the BlueCard pro- vider closest to you Urgent are outside the U.S. are available through the BlueCard Worldwide Network. For Urgent Services when you are within California, but outside of your Personal Physician Service Area, Q. Box 272540 :1. should contact your Personal Physician or Blue Shield Member Services at the number listed on ~~co, CA 95927-2540 Toll-Free Telephone: 1 :~ 88-266- 8080 the last page of this booklet in Section tv., How to Use Your Health Urgent Services when you are within your Personal' Physician Service Area, ' contact your Per- Email Address: blueshieldca-privacy~blueshieldca. com NON-AssIGNABILITY sonal Physician to obtain Urgent Services which must be provided or authorized by your Personal Physician just like all other non-emergency Services of the Plan. lNDEPENDENTCONTRACTORS Benefits of this Plan are not assignable. PLEASE READ THE FOLLOWING MATION . SO YOU WHOM OR WHAT . HEALTH CARE MAY BE OBTAINED. FACILITIES Plan Providers are neither agents nor of the Plan but are independent contractors. Blue Shield of California conducts a proces~ of credentia1ing and certification of all Physicians who participate in the Access+ HM:O Network. ever, in no instance shall the Plan be liable for the negligence, wrongful acts or omissions of any person receiving or providing Services, The Plan has established a network of Physicians, Hospitals, Agencies and Non-Physician Health Care Practitioners in your Personal Physician Service Area. including any Physician, Hospital, or other provider or their employees. The Personal Physician(s) you and your Dependents select will provide telephone access 24 a day, seven days a week so that you can obtain PAYMENT OF PROVIDERS Blue Shield Physicians to provide' Services to Members. assistance and prior approval of Medically Neces57- fixed, monthly fee is paid to the groups of Physi- Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 13 of 31 cians for each Member whose Personal Physician is in the group. ' This payment system, capitatio~ includes incentives to the groups of Allowed Charges the amount a Plan Provider agrees to' accept as payment or the billed amount for non-Plan Providers: those services Benefits (Covered which a Member is ' entitled to receive' pursuant to the terms of the Group Health Service manage all appropriate mariner consistent with the contract. . If you want to know sy~ the last page of this booklet. listed on Contract. Calendar Year 1 a.m., PLAN INTERPRETATION January 1 and ending 12:01 a.m., JanUary 1 of the following year. Blue Shield shall have the power and discretion- ary authority to construe and interpret the provisions otthe contract, to Close Relative the spouse, child, brother, sis- ter, or parent of a Subscriber or Dependent. the contract, and determine eligibility to receive Benefits under the contract. Blue Shield shall exercise this authority for the benefit of all persons entitled to receive Benefits under the contract. AccE&Y+ SATISFACTION Copayment the amount which a Member is surgery that is performed required to pay for certain Benefits. . Cosmetic Surgery to alter or reshape body to improve appearance. You may provide Blue Shield with feedback regarding the service you receive from Plan Physicians. Return the prepaid postcard available Covered Services (Benefits) those services which a Member is entitled to receive pursuant to the terms of the Group Health Service Contract. Member Services to Blue Shield. satisfied with the service provided during an office visit with a Plan Physician, you may request a re- ftmd of your offi~ visit the Summary of Benefits under ~hysician Services. Custodial or Maintenance Care care furnished in the home primarily for supervisory care or supportive XIV. DEFINITIONS primarily to provide room and board or meet the activities of daily living (which may include nursing care, training in personal hygiene a Medical Group or IP and other forms of self care or supervisory care Access+ Provider and all cialists, that participate in the Access+ HMO Plan and for Mental Health and by a Physician); or care furnished to a Member who is mentally or physically disabled, and: 1. who abuse Services, an MHSA Vider. Accidental. Injury cal, or psychiatric treatment to reduce the disability to the extent necessary to enable definite trauma resulting the patient to live outside an providing such care; or, 2. when, reasonable likelihood that the from a sudden event, occurring by chance, caused by an independent ~xterna1 source. Activities of Dally Living (ADL) the self-care and mobility skills required for independence in normal everyday living. This does not will be so reduced. clude recreational or sports activities. services or treatDental Care and ment on or to the teeth or gums whether or not 58- " ... . ~.. . ~, ...- ... .. ::' .... ,- . .- Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 14 of 31 caused by accidental injury, including any appliance or device applied to the teeth or gums. ten certification of Total Disability within 31 days from the date of the Employer's or Blue Shield's request; Dependent 1. a c. ability and is submitted to Blue Shield on the following schedule: not covered for Benefits as a.subscriber and is not legally separated from the Subscriber;. or 2. a Subscriber s Domestic. covered for Benefits as a Subscriber; or 3. a (1) within 6 months after the month when the Dependent would otherwise have been terminated; and (2) annually thereafter on the same month when certification was made in accor- s) unmar- ried child (including any stepchild or child placed for adoption) who is: ' (~) less than 19 years of age; or (b) less than' 2S years of age dance with item (1) event will coverage if' a full-time student and proof of status is submitted' to and received by be continued be- yond the date when child becomes ineligible for coverage under this Plan for any reason other than attained age. Shield. Full-time student means a Dependent must be enrolled in a college, university, vo- ~tiona1, or technical school for a minimum of units as an undergraduate, or 6 units as a ~quate Benefits as a Subscriber, and (d) primarily dependent upon the ~Partner) for support , or is Domestic Partner an individual who is per- sonally related to the tic partnership that meets the quirements: 1. Both partners ~e~dent upon Partner) for medical support by reason of a court order; and who has been enrolled and accepted by Blue Shield of and of the same or different sex; 2. The committed relationship of mutual caring, and (b) the same principal residence; 3. The nor have had maintained membership under the terms of the contract. 4. If terminated because of the attainment of age 19 (or age 25, if time student), and the Dependent child is To- within the last 6 months, unless such for- mer partner is closely related by blood that legal marriage or registered domestic tally Disabled Mentally pendent will be continued upon the following conditions: a. the child would otherwise be prohibited; 4. Both each other s ''basic living expenses " ing the domestic partnership; S. Both dur.,. the Subscriber (or Domestic Partner) for support and mairitenance; partnership began; 6. The domestic consent to a contract when their b. the submits to. Blue Shield a Physician s writ59- the Blue Shield sp~cific Affidavit of Do- Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 15 of 31 mestic Partnership. This affidavit must be in business or service, in which a bona fide coIi1plet~ both. p~ets" an:d submitted to Blue Shield willi the Member' s enrollment application; 7. In nership, the Subscriber and domestic part- employer-employee which the majority of employees ployed within this state, and which was not . formed primarily health care coverage or insurance. Experimental or ner may. submit a specific Declaration of Domestic Partnership .that is filed with a governmental entity:where filing mestic partner arrangements is required by law. Blue Shield Underwriting may waive the required affidavit after review and acceptance . of Partnership issued by a governmental en- any treatment, therapy, procedure, dmg or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supplies which are not dance with. medical standards as being safe and effective for use in the treatment of the illness, injury, or condition at issue. serVices which require approval by the federal government or any agency tity. care provided in a Hospital Domiciliary Care or other licensed facility because care in the patient' s home is not available or is unsuitable. thereof, or by prior to use and where such approval has not been granted at the time the Dues the monthly prepayment that is made to plies were perimental or investigational in nature. the Plan on behalf of each Contractholder. ices or supplies which themselves are not ap- proved or recognized in accordance with accepted professional medical standards, but nevertheless are. authorized by law ernment agency for use in Emergency Services services provided for an unexpected medical condition, including a psychiatric manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could re~oi1ably be expected to result in any of the following: other studies on human patients, shall be considered experimental or investigational in nature. Family ents. the SubsCriber and all enrolled Depend- 1. placing the Member jeopardy; s health in serious GrQup Health Service Contract 2. 3. serious the contract issued by the Plan to the Contractholder that Members are entitled to receive from the Plan. part. Home Medical equipment de- Employee an individual who meets the eligibility requirements set forth Health Service Contract between Blue Shield ofCa1ifornia and your employer. signed for repeated use which is MedicaUy Necessary to treat an illness or injury, to improve the functioning of a any person, firm Employer (Contractholder) proprietary or non-profit corporation, partnership, public agency, or association that has at least 2 employees and that is actively engaged 60- member, or to prevent further deterioration of the patient' s medical condition. . Home Me~cal Equipment includes wheelchairs, Hospital beds, respirators, and other items that the Plan determines are Home Medical Equipment. ":.~.'' ) ;.' , :".~.~':' . ): Document 32-2 Filed 06/24/2005 Page 16 of 31 an entity which pregnancy or to carry a pregnancy to a live Case 5:05-cv-01779-RMW Hospice or Hospice Agency provides Hospice persons and holds a license, currently in effect, as a Safety Code Section 1747, or a home health agency licensed pursuant to He81th and Safety . birth after a year or more of relations without contraception. Inpatient an individual who has been admit- ted to a Hospital as a registered bed patient Code Sections Medicare certification. and is receiving services under the direction of a Physician. Hospital1. a ), (3.) or (4.) below: Intensive Outpatient Care Program an Out- patient Mental Health (or treatment program utilized when a patient' condition requires structure, monitoring, and medicaVpsychological intervention at least hours per day, 3 times per week. is primarily engaged in providing, for compensation from and surgical facilities for the care and treatment of sick and injured patient basis, and which provides such facili~ ties under the supervision of a staff of Physicians . and 24 hour a day nursing registered nurses. facility which is principally'" a rest home, nursing home or home for the aged is not included; or 2. a Late Enrollee an eligible pendent who has declined Plan at the time of the initial riod, and who ment in this Plan; provided that the initial enrollment period shall be a period of at least 30 days. However, an eligible pendent will not be considered a Late Enrollee if any of the conditions listed under (1.), (2. (3. ), (4.), (5.) or (6.) below is applicable: I. The cility. accredited by the Joint Commission on Accreditation of Health Care Organizations; or 3. for the treatment of alcoholism and/or sub- meets all of the (a.), (b.), (c.) and (d. a. The Employee or Dependent was zations; or 4. a ' 'psychiatric health facility" Section 1250.2 stance abuse accredited by the Joint Commission on Accreditation of Health Care Organias defined in ered un~er another employer health benefi~ plan at the time he was enrol1ment under this Plan; b. The Employee or Dependent of the Health and Safety Code. Independent Practice group of Physicians with at the time of the initial that coverage under another employer who form an organization in order to contract, manage , and share health benefit plan was the reason for declining enrollment provided that, he was for providing Benefits to Mental Health and. substance abuse Services this definition includes' the SerVices Administrator (MHSA). ployer health plan, he was given the opportunity to make the certification Infertility either (1) the presence of a demonstrated bodily malfunction recognized by a licensed Doctor of Medicine as a cause of In- required and was notified that failure to do so could resliIt in later treatment as a Late Emollee; fertility, or (2) bodily malfunction, the inability to conceive a 61- . c. . or will lose Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 17 of 31 employer health benefit pl~ . as a sult of tennination' of his employment or of an individual through time of his later decision to el~ct cover- age, an e~clusion from coverage for a period of 12 months, unless he or she meets . the criteria specified in . - . (2.) or (3.) was covered as a Dependent, change. in his employment status or of an in- above; or dividual through whom he was covered as a Dependent, 5. For the other plan s coverage, of exhaustion contribu- will lose their no Cal . cessation of an employet' s cOverage and who within 31 days after tion toward his coverage, death of an individual through whom he was covered as a Dependent, or legal tion or divorce; and d. The Employee or Dependent .. loss of coverage; or 6. For erage dming the initial enrollment period and through tnarriage, birth, or placement for adoptio~ and who enroll for coverage for themselves and their 31 days from the date of marriage; birth, or placement for adoption. enrollment within 31 days after termination of coverage or employer contribution toward coverage provided un- der another employer health benefit plan; or 2. The employer Medical Group an organization of Physicians who are generally located in the same. and provide Benefits to fit plans and the eligible this Plan during an open riod; or 3. A ' all Mental Health and substance abuse Services, this definition includes the Services Administrator (MHSA). Medically 1. Benefits are coverage be provided for a spouse .or minor child under a covered Employee s health benefit Plan. The health Plan shall enroll a Dependent child within 31 days of presentation of a are Medically Necessary. court order by the district upon presentation of a court order or request by a custodial party, as described in Section 3751.5 of the Family Code; or 2. clude only those which have been established as safe and effective and are furnished in accordance with generally accepted professional standards to treat an illness, injury, or medical condition, and which, as determined by Blue Shield, are: 4. For who fail to during their initial enrollment period, the Plan cannot produce a written ttom the employer stating that prior to declining coverage, he or a. b. icy; and sis; and, c. not ience of the patient, the attending Physi- .:,....r through whom he was covered as a De- pendent, was provided with and acknowledgment of a Refusal of Personal Coverage specifying that failure to coverage during the initial enrollment period permits the Plan to impose, at the cian or other provider; and, 62- Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 18 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 19 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 20 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 21 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 22 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 23 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 24 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 25 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 26 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 27 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 28 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 29 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 30 of 31 Case 5:05-cv-01779-RMW Document 32-2 Filed 06/24/2005 Page 31 of 31

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