Brown v. Google, Inc. et al

Filing 32

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

Dockets.Justia.com

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 mylifepath.com
Group
An Ir\CIependent Member of the Blue Shield Assodatlon

Case 5:05-cv-01779-RMW

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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)

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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.

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Case 5:05-cv-01779-RMW

Document 32-2

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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.

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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

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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.)

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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

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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. mylifepath.com.

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

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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 http://www.mylifepath.com.

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

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. 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 (http://www.hmohelp.ca.gov) 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

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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 http://Www.mylifepath.com

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-

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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
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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-

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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

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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-

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