IT IS UNDERSTOOD AND AGREED THAT THE FOLLOWING MODIFICATIONS SHALL BE MADE:
- The following provision will be added to the BENEFITS section of the Plan document:
The Plan does not require certification for emergency services. - In the introductory sections of both the SCHEDULE OF MEDICAL BENEFITS –BLACK PLAN and the SCHEDULE OF MEDICAL BENEFITS – ORANGE PLAN
sections of the Plan document, the following two changes will be made:
A. The first note will be revised to read as follows:
As required by the No Surprises Act, if a Covered Person receives services in the following situations, the services will be paid at the In-Network benefit level: (1) emergency care; (2) transportation by air ambulance; or (3) nonemergency care at an In-Network facility provided by an Out-of- Network Physician or laboratory, unless the Covered Person provides informed consent.
Additionally, if a Covered Person receives eligible treatment at an In-Network facility, any charges for the following will be paid at the In-Network benefit level, even if provided by an Out-of-Network Physician or laboratory: (1) anesthesiology, pathology, radiology, or neonatology; (2) assistant surgeons, hospitalists, or intensivists; (3) diagnostic services (including radiology and laboratory services); and (4) items and services provided by an Out-of-Network Physician or laboratory if there was no In-Network Physician or laboratory that could provide the item or service at the In-Network facility.
B. The final note will be revised to read as follows:
Certification is required for all Inpatient Hospital admissions, select surgical procedures, and some Outpatient procedures. Please see the “Utilization
Review Program” subsection for specific information regarding requirements and deadlines. - The following will be added to the UTILIZATION OF IN-NETWORK PROVIDERS section of the Plan document:
A Covered Person who is a Continuing Care Patient will receive a notice that the Covered Person may elect to receive transitional care. If the Covered Person timely notifies the Plan of the Covered Person’s need for transitional care, charges from the In-Network Provider that moved Out-of-Network will continue to be paid at the In-Network benefit level (and subject to the same terms and conditions that apply In-Network) for a period of 90 days or, if earlier, the date that the Covered Person is no longer a Continuing Care Patient. This 90-day period begins on the date that the Covered Person receives the notice regarding transitional care. A Covered Person who is a Continuing Care Patient is not eligible for transitional care if the In-Network Provider is removed from the network for
failure to meet applicable quality standards or for fraud. - The following two changes will be made to the UTILIZATION REVIEW PROGRAM section of the Plan document:
A. The following new provision will be added:
The Plan does not require certification for emergency services.
B. The MANDATORY OUTPATIENT SERVICE CERTIFICATION subsection will be deleted in its entirety and replaced with the following:
MANDATORY SELECT SURGICAL PROCEDURE AND OUTPATIENT SERVICE CERTIFICATION
If a Covered Person’s treatment includes any of the following services, the treatment should be reviewed before its inception, regardless of whether or not the
treatment is in lieu of hospitalization:
A. Select surgical procedures*
B. Durable Medical Equipment if the purchase price or forecasted total rental cost is $2,500 or more
C. Home Health Care
D. Custom-made Orthotic or Prosthetic Appliance if the purchase price is $2,500 or more
E. Outpatient oncology treatment (chemotherapy or radiation therapy)
F. Outpatient infusion or injection of select products*
*The list of the select surgical procedures and the list of infusion or injection products requiring certification can both be viewed by logging on to the Claim Administrator’s Website address printed on the back of the Covered Person’s identification card or by calling the Claim Administrator at the telephone number
printed on the back of the Covered Person’s identification card.
A Covered Person must call the telephone number on the front of his or her health plan identification card as soon as possible before receiving the above listed services, but in no event later than two business days after the services were rendered. - The following two new defined terms will be added to the DEFINITIONS section of the Plan document:
CONTINUING CARE PATIENT
The term “Continuing Care Patient” means a Covered Person who (1) is undergoing a course of treatment for a serious and complex condition from an In-Network Provider; (2) is undergoing a course of institutional or Inpatient care from an In-Network Provider; (3) is scheduled to undergo non-elective surgery from an In-Network Provider, including receipt of postoperative care from the In-Network Provider with respect to the non-elective surgery; (4) is pregnant and undergoing a course of treatment for the Pregnancy from the In-Network Provider; or (5) is or was determined to be terminally ill and is receiving treatment for the terminal Illness from the In-Network Provider.
NO SURPRISES ACT
The term “No Surprises Act” refers to the provisions in Sections 716 and 717 of ERISA, as amended. - In the DEFINITIONS section of the Plan document, the following new note will be added to the USUAL AND CUSTOMARY definition:
NOTE: For claims that are subject to the No Surprises Act, the No Surprises Act governs the calculation of the payment amount by the Plan for purposes of determining both (1) the covered Person’s cost-sharing requirement, and (2) the total payment, net of the Covered Person’s cost-sharing requirement, to the Physician or other provider. For example, these amounts may be calculated using the Qualifying Payment Amount, which is generally the median of the Plan’s contracted rate with In-Network Providers for the same item or service in the same geographic area. The payment amount for other Out-of-Network claims may
be calculated in this same manner, subject to the Plan Administrator’s discretion.
All other provisions of the Plan shall remain in effect and unchanged.
IN WITNESS WHEREOF, the undersigned has caused this amendment to be duly adopted and
effective as of January 1, 2022.
Signatures on file in Human Resources.